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Škorić B, Jovanović M, Kuzmanović M, Miljković B, Vučićević K. Understanding hemoglobin contribution to high-dose methotrexate disposition-population pharmacokinetics in pediatric patients with hematological malignancies. Eur J Clin Pharmacol 2024; 80:697-705. [PMID: 38347227 DOI: 10.1007/s00228-024-03642-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 02/01/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE The aim of the present study was to develop a population pharmacokinetic model for methotrexate (MTX) during high-dose treatment (HDMTX) in pediatric patients with acute lymphoblastic leukemia (ALL) and non-Hodgkin's lymphoma (NHL) and to describe the influence of variability factors. METHODS The study included 50 patients of both sexes (aged 1-18 years) who received 3 or 5 g/m2 of HDMTX. A nonlinear mixed effect modeling approach was applied for data analysis. Parameter estimation was performed by first-order conditional estimation method with interaction (FOCEI), whereas stepwise covariate modeling was used to assess variability factors. RESULTS The final model is a two-compartment model that incorporates the effect of body surface area and the influence of hemoglobin and serum creatinine on MTX clearance (CL). Population pharmacokinetic values for a typical subject were estimated at 5.75 L/h/m2 for clearance (CL), 21.3 L/m2 for volume of the central compartment (V1), 8.2 L/m2 for volume of the peripheral compartment (V2), and 0.087 L/h/m2 for intercompartmental clearance (Q). According to the final model, MTX CL decreases with increasing serum creatinine, whereas a positive effect was captured for hemoglobin. A difference of almost 32% in MTX CL was observed among patients' hemoglobin values reported in the study. CONCLUSION The developed population pharmacokinetic model can contribute to the therapy optimization during HDMTX in pediatric patients with ALL and NHL. In addition to renal function and body weight, it describes the influence of hemoglobin on CL, allowing better understanding of its contribution to the disposition of HDMTX.
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Affiliation(s)
- Biljana Škorić
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221, Belgrade, Republic of Serbia
| | - Marija Jovanović
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221, Belgrade, Republic of Serbia
| | - Miloš Kuzmanović
- University of Belgrade-School of Medicine, Belgrade, Republic of Serbia
- Pediatric Clinic, Institute for Mother and Child Healthcare of Serbia "Dr Vukan Čupić", Belgrade, Republic of Serbia
| | - Branislava Miljković
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221, Belgrade, Republic of Serbia
| | - Katarina Vučićević
- Department of Pharmacokinetics and Clinical Pharmacy, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe 450, 11221, Belgrade, Republic of Serbia.
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Abdel-Wahab WM, Daifalla NS, Essawy AE. L-methionine protects against nephrotoxicity induced by methotrexate through modulation of redox status and inflammation. Redox Rep 2023; 28:2270886. [PMID: 37931136 PMCID: PMC10629423 DOI: 10.1080/13510002.2023.2270886] [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] [Indexed: 11/08/2023] Open
Abstract
Objective: Methotrexate (MTX) is a drug used in the treatment of cancer and autoimmune disorders; however, its clinical use is limited because of serious side effects including renal toxicity. This study aimed to investigate the protective effect of Lmethionine (L-Met) on MTX toxicity in the kidneys of rats.Methods: Thirty male rats were divided equally into five groups: control (saline), Met400 (400 mg/kg L-Met), MTX (20 mg/kg MTX), MTX-Met300 (300 mg/kg L-Met and 20 mg/kg MTX), and MTX-Met400 (400 mg/kg L-Met and 20 mg/kg MTX). Rats were euthanized one day after the last dose administration (day 16) and serum and renal tissue samples were collected. Renal function and injury indices, oxidative stress/antioxidant indices and proinflammatory cytokines were evaluated.Results: The results showed that L-Met could effectively counteract the nephrotoxic effects of MTX, in a dose-related manner, by improving most of the tested parameters. Furthermore, the higher dose of L-Met was able to restore several parameters to normal levels. In addition, investigation of MTX-induced hematological changes revealed a corrective potential of L-Met.Conclusion: L-Met can be an effective adjuvant therapy to modulate renal toxicity associated with MTX because of its antioxidant and antiinflammatory effects.
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Affiliation(s)
- Wessam M. Abdel-Wahab
- Department of Zoology, Faculty of Science, Alexandria University, Alexandria, Egypt
- Department of Basic Sciences, Deanship of Preparatory Year and Supporting Studies, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Nada S. Daifalla
- Department of Basic Sciences, Deanship of Preparatory Year and Supporting Studies, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Amina E. Essawy
- Department of Zoology, Faculty of Science, Alexandria University, Alexandria, Egypt
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3
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Parrilla M, Detamornrat U, Domínguez-Robles J, Tunca S, Donnelly RF, De Wael K. Wearable Microneedle-Based Array Patches for Continuous Electrochemical Monitoring and Drug Delivery: Toward a Closed-Loop System for Methotrexate Treatment. ACS Sens 2023; 8:4161-4170. [PMID: 37856156 DOI: 10.1021/acssensors.3c01381] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
Wearable devices based on microneedle (MN) technology have recently emerged as tools for in situ transdermal sensing or delivery in interstitial fluid (ISF). Particularly, MN-based electrochemical sensors allow the continuous monitoring of analytes in a minimally invasive manner through ISF. Exogenous small molecules found in ISF such as therapeutic drugs are ideal candidates for MN sensors due to their correlation with blood levels and their relevance for the optimal management of personalized therapies. Herein, a hollow MN array patch is modified with conductive pastes and functionalized with cross-linked chitosan to develop an MN-based voltammetric sensor for continuous monitoring of methotrexate (MTX). Interestingly, the chitosan coating avoids biofouling while enabling the adsorption of MTX at the electrode's surface for sensitive analysis. The MN sensor exhibits excellent analytical performance in vitro with protein-enriched artificial ISF and ex vivo under a Franz diffusion cell configuration. The MN sensor shows a linear range from 25 to 400 μM, which fits within the therapeutic range of high-dose MTX treatment for cancer patients and an excellent continuous operation for more than two days. Moreover, an iontophoretic hollow MN array patch is developed with the integration of both the anode and cathode in the single MN array patch. The ex vivo characterization demonstrates the transdermal on-demand drug delivery of MTX. Overall, the combination of both MN patches represents impactful progress in closed-loop systems for therapeutic drug management in disorders such as cancer, rheumatoid arthritis, or psoriasis.
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Affiliation(s)
- Marc Parrilla
- A-Sense Lab, Department of Bioscience Engineering, University of Antwerp, Groenenborgerlaan 171, 2020 Antwerp, Belgium
- NANOlab Center of Excellence, University of Antwerp, Groenenborgerlaan 171, 2020 Antwerp, Belgium
| | - Usanee Detamornrat
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, U.K
| | - Juan Domínguez-Robles
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, U.K
- Department of Pharmacy and Pharmaceutical Technology, University of Seville, 97 Lisburn Road, Seville 41004, Spain
| | - Sensu Tunca
- A-Sense Lab, Department of Bioscience Engineering, University of Antwerp, Groenenborgerlaan 171, 2020 Antwerp, Belgium
- NANOlab Center of Excellence, University of Antwerp, Groenenborgerlaan 171, 2020 Antwerp, Belgium
| | - Ryan F Donnelly
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, U.K
| | - Karolien De Wael
- A-Sense Lab, Department of Bioscience Engineering, University of Antwerp, Groenenborgerlaan 171, 2020 Antwerp, Belgium
- NANOlab Center of Excellence, University of Antwerp, Groenenborgerlaan 171, 2020 Antwerp, Belgium
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4
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Fan J, Jiang T, He D. Advances in the implications of the gut microbiota on the treatment efficacy of disease-modifying anti-rheumatic drugs in rheumatoid arthritis. Front Immunol 2023; 14:1189036. [PMID: 37841256 PMCID: PMC10568326 DOI: 10.3389/fimmu.2023.1189036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023] Open
Abstract
Alterations in the composition or function of the gut microbiota are associated with the etiology of human diseases. Drug-microbiota interactions can affect drug bioavailability, effectiveness, and toxicity through various routes. For instance, the direct effect of microbial enzymes on drugs can either boost or diminish their efficacy. Thus, considering its wide range of metabolic capabilities, the gut microbiota is a promising target for pharmacological modulation. Furthermore, drugs can alter the microbiota and the mechanisms by which they interact with their host. Individual variances in microbial profiles can also contribute to the different host responses to various drugs. However, the influence of interactions between the gut microbiota and drugs on treatment efficacy remains poorly elucidated. In this review, we will discuss the impact of microbiota dysbiosis in the pathogenesis of rheumatoid arthritis (RA), and we will attempt to elucidate the crosstalk between the gut microbiota and disease-modifying anti-rheumatic drugs (DMARDs), with an emphasis on how drug-microbiota interactions affect the treatment efficacy in RA. We speculate that improved knowledge of these critical interactions will facilitate the development of novel therapeutic options that use microbial markers for predicting or optimizing treatment outcomes.
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Affiliation(s)
- Junyu Fan
- Department of Rheumatology, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Rheumatology, Shanghai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, China
| | - Ting Jiang
- Department of Rheumatology, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Rheumatology, Shanghai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, China
| | - Dongyi He
- Department of Rheumatology, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Rheumatology, Shanghai Guanghua Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai, China
- Institute of Arthritis Research in Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, Shanghai, China
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5
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Mu J, Zhang H, Huang Z, Jia Q. Terbium-triggered aggregation-induced emission of bimetallic nanoclusters for anticancer drugs sensing via the inner filter effect. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2023; 291:122388. [PMID: 36696862 DOI: 10.1016/j.saa.2023.122388] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 06/17/2023]
Abstract
The development of accurate and sensitive detection methods of anticancer drugs is of significant importance because they play vital roles in biological systems. In recent years, bimetallic nanoclusters (BMNCs) incorporating the advantages of two metals have gained more and more attention, and can be widely applied in sensing applications. In this work, for the first time, we designed a sensing platform based on terbium ion (Tb3+) triggered aggregation-induced emission (AIE) of BMNCs. Tb3+ hybrid glutathione (GS) protected Ag/Cu nanoclusters (Tb3+@GS-AgCuNCs) were facilely fabricated according to the complexation reaction between Tb3+ and the carboxyl group of GS. Due to the inner filter effect (IFE), the fluorescence of Tb3+@GS-AgCuNCs decreased significantly in the presence of anticancer drugs with 6-thioguanine and methotrexate as representatives. In addition, the sensing platform was applied to monitor 6-thioguanine and methotrexate in real serum samples, indicating that it has great potential in anticancer drugs related applications.
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Affiliation(s)
- Jin Mu
- College of Chemistry, Jilin University, Changchun 130012, China
| | - Huifeng Zhang
- Institute of Agricultural Quality Standards and Testing Technology, Jilin Academy of Agricultural Sciences, Changchun 130033, China
| | - Zhenzhen Huang
- College of Chemistry, Jilin University, Changchun 130012, China
| | - Qiong Jia
- College of Chemistry, Jilin University, Changchun 130012, China.
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6
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He J, Wang J, Zhang M, Shi G. Ultrasensitive therapeutic drug monitoring of methotrexate by a structure-switching aptamer with cascade primer exchange reaction. Analyst 2023; 148:222-226. [PMID: 36533310 DOI: 10.1039/d2an01658c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
As a folate antagonist, methotrexate (MTX) has been widely used in clinics with good effects on various tumors and inflammatory diseases. While the optimum dosage and total body clearance of MTX usually varies between individuals and even low-dose MTX has side effects, high-dose MTX may cause life-threatening side effects. Therefore, a convenient and simple method toward MTX sensing is highly demanded. Herein, we report a highly sensitive and selective method for therapeutic drug monitoring (TMD) of MTX by integrating a highly specific MTX-dependent structure-switching aptamer with a primer exchange reaction-based signal amplification technique. The detection limit is down to 1.7 nM with a linear range from 0.01 to 1 μM in buffer. More importantly, the sensing strategy can effectively detect MTX in a complex bio-environment with a linear response range from 0.05 to 2 μM and a LOD of 12.4 nM in 10% FBS and a range of 0.2 to 5 μM with a LOD of 63.73 nM in 10% whole blood. Considering the high sensitivity and selectivity and good performance in blood, the method reported herein paves a new avenue for the effective determination of MTX in clinics.
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Affiliation(s)
- Junqing He
- School of Chemistry and Molecular Engineering, Shanghai Key Laboratory for Urban Ecological Processes and Eco-Restoration, East China Normal University, Shanghai 200241, China.
| | - Junyan Wang
- Institute of Molecular Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Min Zhang
- School of Chemistry and Molecular Engineering, Shanghai Key Laboratory for Urban Ecological Processes and Eco-Restoration, East China Normal University, Shanghai 200241, China.
| | - Guoyue Shi
- School of Chemistry and Molecular Engineering, Shanghai Key Laboratory for Urban Ecological Processes and Eco-Restoration, East China Normal University, Shanghai 200241, China.
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7
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Hamed KM, Dighriri IM, Baomar AF, Alharthy BT, Alenazi FE, Alali GH, Alenazy RH, Alhumaidi NT, Alhulayfi DH, Alotaibi YB, Alhumaidan SS, Alhaddad ZA, Humadi AA, Alzahrani SA, Alobaid RH. Overview of Methotrexate Toxicity: A Comprehensive Literature Review. Cureus 2022; 14:e29518. [PMID: 36312688 PMCID: PMC9595261 DOI: 10.7759/cureus.29518] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2022] [Indexed: 02/05/2023] Open
Abstract
Methotrexate (MTX) is significantly more effective than and has a considerable advantage over placebo in patients with severe and persistent rheumatoid arthritis (RA). The drug is used to treat a variety of malignant disorders (leukemia and cancer of the lung, breast, and uterus) and ectopic pregnancy. As its side effects are outweighed by its effectiveness, MTX is a first-line antirheumatic drug in many countries. MTX is found in extracellular compartments, such as the synovium, as well as other organs, such as the kidney and liver. To improve treatment, increase adherence, and decrease mortality in MTX therapy, it is essential to reduce its toxicity and understand its side effects. Therefore, this comprehensive review was conducted to assist physicians and researchers in better understanding the toxicity of MTX and how to deal with this toxicity. MTX is eliminated via the kidneys, which are capable of excretion and reabsorption within the renal tubules. Although higher doses of MTX (known as high-dose MTX (HD-MTX), defined as doses of 500 mg/m2 or greater) are often more beneficial, they can produce toxicity and side effects such as bone marrow suppression, pulmonary toxicity, nephrotoxicity, hematologic toxicity, and an increased risk of infections. Treatment of severe MTX toxicity has three main goals: clearance of MTX from the bloodstream, folinic acid therapy, and organ treatment. Leucovorin is highly beneficial in preventing myelosuppression, gastric toxicity, and neurotoxic effects after HD-MTX therapy. The preferred antidote for MTX poisoning is folinic acid. Glucarpidase has been licensed for the treatment of high plasma MTX levels of >1 μmol/L in patients with compromised renal function who have delayed MTX elimination. In patients with renal deficiency, a lower initial dose is considered with an estimated glomerular filtration rate (eGFR) between 30 and 59 mL/minute. These patients need to be monitored, and a more gradual dosage increase and a lower weekly maximum should be considered regarding their general health situation. MTX is contraindicated in patients with RA if the eGFR is <30 mL/minute.
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Affiliation(s)
| | | | | | - Baidaa T Alharthy
- Pharmaceutical Care, General Network for Healthcare Providers Hospital, Jeddah, SAU
| | | | | | - Rawan H Alenazy
- General Medicine and Surgery, Northern Border University, Arar, SAU
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8
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Yu Y, Huang Z, Chen Q, Zhang Z, Jiang H, Gu R, Ding Y, Hu Y. Iron-based nanoscale coordination polymers synergistically induce immunogenic ferroptosis by blocking dihydrofolate reductase for cancer immunotherapy. Biomaterials 2022; 288:121724. [PMID: 36038420 DOI: 10.1016/j.biomaterials.2022.121724] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/26/2022] [Accepted: 08/02/2022] [Indexed: 01/18/2023]
Abstract
Iron is indispensable for cancer cell survival and cancer cells are more vulnerable to ferroptosis than normal cells. Ferroptosis holds promise for overcoming chemoresistance and inducing tumor immunogenic cell death, which offers new possibilities for cancer immunotherapy. However, the prevalence of immunogenic ferroptosis in cancer cells is diminished because of the high levels of reducing substances within tumor microenvironments. Ferroptosis-needed iron is overdose for livings, which is also an obstacle for effective immune responses. In this study, we construct self-assembled carrier-free nanoscale coordination polymers based on iron and methotrexate (MFe-NCPs). The low-dose-iron-induced immunogenic ferroptosis is obviously enhanced by methotrexate via inhibiting dihydrofolate reductase and abating substance reduction, respectively. Of note, MFe-NCPs sequentially promoted antigen presentation, immune activation, T cell infiltration and boosted the therapeutic effect of immune checkpoint blockade therapy.
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Affiliation(s)
- Yue Yu
- Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China; State Key Laboratory of Pharmaceutical Biotechnology, Medical School & School of Life Sciences, Nanjing University, Nanjing, China
| | - Zhusheng Huang
- State Key Laboratory for Organic Electronics and Information Displays and Jiangsu Key Laboratory for Biosensors, Institute of Advanced Materials (IAM), Nanjing University of Posts and Telecommunications, Nanjing, China
| | - Qian Chen
- State Key Laboratory of Pharmaceutical Biotechnology, Medical School & School of Life Sciences, Nanjing University, Nanjing, China
| | - Zhicheng Zhang
- Department of Radiation Oncology, Key Laboratory of Cancer Prevention and Intervention, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Haojie Jiang
- State Key Laboratory of Pharmaceutical Biotechnology, Medical School & School of Life Sciences, Nanjing University, Nanjing, China
| | - Rong Gu
- State Key Laboratory of Pharmaceutical Biotechnology, Medical School & School of Life Sciences, Nanjing University, Nanjing, China
| | - Yitao Ding
- Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.
| | - Yiqiao Hu
- State Key Laboratory of Pharmaceutical Biotechnology, Medical School & School of Life Sciences, Nanjing University, Nanjing, China.
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9
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Jiang R, Mei S, Zhao Z. Leucovorin (folinic acid) rescue for high-dose methotrexate: A review. J Clin Pharm Ther 2022; 47:1452-1460. [PMID: 35929573 DOI: 10.1111/jcpt.13739] [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: 03/06/2022] [Revised: 06/20/2022] [Accepted: 06/24/2022] [Indexed: 11/29/2022]
Abstract
High-dose methotrexate (HDMTX) is active against various malignancies; it possesses serious toxicities and is associated with patient characteristics, dosage regimens, comedications, and physiological status. There are many strategies to overcome HDMTX-induced toxicities, such as hydration, alkalization, leucovorin rescue, and haemodialysis. Leucovorin rescue is a cornerstone for toxicity prevention in HDMTX treatment. However, the leucovorin dose adjustment and the existence of leucovorin overrescue are still controversial. At present, various methods for calculating leucovorin doses in different tumour types have been proposed, including empirical calculations based on MTX plasma concentration, the Bleyer nomogram, and other methods. Nonetheless, leucovorin rescue protocols differ greatly across tumour types and medical institutions. Further studies are needed to investigate the optimal dosage regimen for leucovorin rescue in various tumours using HDMTX.
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Affiliation(s)
- Ruiqi Jiang
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, People's Republic of China
| | - Shenghui Mei
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, People's Republic of China
| | - Zhigang Zhao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,Department of Clinical Pharmacology, College of Pharmaceutical Sciences, Capital Medical University, Beijing, People's Republic of China
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10
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Mailankody S, Kumar VS, Khan SA, Banavali SD, Bajpai J. Resource-appropriate selection of osteosarcoma treatment protocols in low- and middle-income countries. Pediatr Blood Cancer 2022; 69:e29540. [PMID: 34971016 DOI: 10.1002/pbc.29540] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 10/30/2021] [Accepted: 12/08/2021] [Indexed: 02/01/2023]
Abstract
Osteosarcoma is a rare malignancy; however, it is still the most common primary bone tumor in adolescents and young adults. Chemotherapy improves survival indubitably in osteosarcoma; nevertheless, the concern is the stagnant progress since the last several decades. There are a handful of active agents and unresolved issues, especially in choosing the ideal chemotherapy regimen. The oncology community is in equipoise regarding the position of high-dose methotrexate (HDMTX), mandatory or adjunct. The choice of therapy becomes widely relevant, including in low- and middle-income countries (LMIC), where HDMTX administration brings additional complexities. Research into novel non-HDMTX-based protocols adapted to the available resources is pivotal in improving disease outcomes, especially in LMIC. The current review focuses on real-world challenges in decision-making and provides a comprehensive overview of the evolution of treatment protocols in LMIC.
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Affiliation(s)
- Sharada Mailankody
- Department of Medical Oncology, Manipal Comprehensive Cancer Care Centre, Kasturba Medical College, Manipal, Karnataka, India.,Manipal Academy of Higher Education, Manipal, Karnataka, India
| | | | - Shah Alam Khan
- Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, India
| | - Shripad D Banavali
- Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute (HBNI), Mumbai, Maharasthra, India
| | - Jyoti Bajpai
- Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute (HBNI), Mumbai, Maharasthra, India
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11
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Zhang M, He J, Zheng Y, Shi G, Zhang M. Aptamer-engineered extended-gate field-effect transistor device for point-of-care therapeutic drug monitoring. Analyst 2022; 147:4413-4416. [DOI: 10.1039/d2an01393b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A portable point-of-care testing (POCT) device based on an aptamer-engineered extended-gate field-effect transistor (EG-FET) was unveiled for therapeutic monitoring of the drug methotrexate.
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Affiliation(s)
- Mengyang Zhang
- School of Chemistry and Molecular Engineering, Shanghai Key Laboratory for Urban Ecological Processes and Eco-Restoration, East China Normal University, Shanghai 200241, China
| | - Junqing He
- School of Chemistry and Molecular Engineering, Shanghai Key Laboratory for Urban Ecological Processes and Eco-Restoration, East China Normal University, Shanghai 200241, China
| | - Youbin Zheng
- Department of Chemical Engineering, Technion – Israel Institute of Technology, Haifa 320003, Israel
| | - Guoyue Shi
- School of Chemistry and Molecular Engineering, Shanghai Key Laboratory for Urban Ecological Processes and Eco-Restoration, East China Normal University, Shanghai 200241, China
| | - Min Zhang
- School of Chemistry and Molecular Engineering, Shanghai Key Laboratory for Urban Ecological Processes and Eco-Restoration, East China Normal University, Shanghai 200241, China
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12
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Yin L, Ji Z, Cao H, Li Y, Huang J. Comparison of LC-MS 3 and LC-MRM strategy for quantification of methotrexate in human plasma and its application in therapeutic drug monitoring. J Pharm Biomed Anal 2021; 205:114345. [PMID: 34492453 DOI: 10.1016/j.jpba.2021.114345] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 07/24/2021] [Accepted: 08/25/2021] [Indexed: 11/19/2022]
Abstract
A simple, highly selective and high throughput liquid chromatography tandem mass spectrometry cubed (LC/MS3) method was developed and validated for quantification of methotrexate in human plasma. The MS3 detection is a scanning mode of QTrap MS systems or ion trap MS systems. After simple protein precipitation with methanol, methotrexate and methotrexate-d3 were separated on an Agilent Poroshell 120 SB-C18 column (4.6 × 50 mm, 2.7 µm) using isocratic elution with a mobile phase consisting of 60% 0.1% formic acid in water and 40% 0.1% formic acid in acetonitrile. The flow rate is 0.8 mL/min. MS3 detection in positive ion mode used the MRM3 transitions at m/z 455.2→308.2→175.1 for quantification of methotrexate and m/z 458.2→311.2→175.1 for quantification of methotrexate-d3. The total run time was only 3 min for each sample. The LC/MS3 assay was linear in the concentration range 10-3000 ng/mL(R2 ≥ 0.995) and the intra- and inter-day accuracies were< 3.72% and precisions were< 7.78% at all concentrations. The absolute recoveries (%) and matrix effect (%) for methotrexate in human plasma were between 92.6 and 114.3. The novelty of the presented methodology is the MS3 technique resulting in enhanced selectivity and sensitivity. The application of this LC-MS3 method was successfully completed on 46 human plasma samples and the quantitative results of identical human plasma samples were compared with another LC-MRM based method. Passing-Bablok regression coefficients demonstrated that there is no significant difference between the LC-MS3 method and LC-MRM method. Bland-Altman plots showed a concordant results, supporting the developed LC-MS3 method is a reliable and accurate assay for determination of methotrexate in human plasma. This work is also a proof of concept for using LC-MS3 technique to determination of chemicals in biological samples.
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Affiliation(s)
- Lei Yin
- Department of Laboratory Medicine, The First Hospital of Jilin University, Jilin University, Xinmin Street, Changchun 130061, PR China; School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin 124221, PR China.
| | - Zhengchao Ji
- Department of Laboratory Medicine, The First Hospital of Jilin University, Jilin University, Xinmin Street, Changchun 130061, PR China
| | - Haiwei Cao
- Department of Laboratory Medicine, The First Hospital of Jilin University, Jilin University, Xinmin Street, Changchun 130061, PR China
| | - Yanyan Li
- Department of Laboratory Medicine, The First Hospital of Jilin University, Jilin University, Xinmin Street, Changchun 130061, PR China.
| | - Jing Huang
- Department of Laboratory Medicine, The First Hospital of Jilin University, Jilin University, Xinmin Street, Changchun 130061, PR China.
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13
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He J, Wang J, Zhang M, Shi G. Selection of a Structure-Switching Aptamer for the Specific Methotrexate Detection. ACS Sens 2021; 6:2436-2441. [PMID: 34132539 DOI: 10.1021/acssensors.1c00749] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Methotrexate (MTX), a folate antagonist drug, has been widely used for treating various cancers. Since high-dose MTX treatment can cause unwanted serious side effects, tracking the blood concentration of MTX is essential for safe medication. However, available methods are often complex, time-consuming, and expensive. In this study, a highly selective DNA aptamer was selected for recognizing MTX based on a capture-systematic evolution of ligands by an exponential enrichment (C-SELEX) approach. Taking advantage of our selected MTX aptamer, we further unveil a novel structure-switching fluorescent sensor for the specific and rapid monitoring of MTX with good analytical performances (i.e., a linear detection range of 0.1-2 μM with a low detection limit (LOD) of 0.03 μM in buffer and a linear detection range of 0.5-10 μM with an LOD of 0.18 μM in 50% serum). Compared with conventional methods, this assay has great potential for detecting the blood concentration of MTX in clinical use. By coupling with other sensory techniques, our presented aptamer will potentially inspire the development of various sensors toward the monitoring of MTX.
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Affiliation(s)
- Junqing He
- School of Chemistry and Molecular Engineering, Shanghai Key Laboratory for Urban Ecological Processes and Eco-Restoration, East China Normal University, Dongchuan Road 500, Shanghai 200241, China
| | - Junyan Wang
- Institute of Molecular Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Min Zhang
- School of Chemistry and Molecular Engineering, Shanghai Key Laboratory for Urban Ecological Processes and Eco-Restoration, East China Normal University, Dongchuan Road 500, Shanghai 200241, China
| | - Guoyue Shi
- School of Chemistry and Molecular Engineering, Shanghai Key Laboratory for Urban Ecological Processes and Eco-Restoration, East China Normal University, Dongchuan Road 500, Shanghai 200241, China
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14
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Pesenti G, Foppoli M, Manca D. A minimal physiologically based pharmacokinetic model for high-dose methotrexate. Cancer Chemother Pharmacol 2021; 88:595-606. [PMID: 34120234 PMCID: PMC8367929 DOI: 10.1007/s00280-021-04305-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 05/30/2021] [Indexed: 11/18/2022]
Abstract
Purpose High-dose methotrexate (HDMTX) is administered for the treatment of a variety of malignant tumors. Wide intra- and inter-individual variabilities characterize the pharmacokinetics of MTX, which is mostly excreted renally. HDMTX dosages are prescribed as a function of body surface area whereas dose adjustments depending on renal function are not well defined. We develop a population pharmacokinetic model with a physiological description of renal excretion as the basis for clinical tools able to suggest model-informed dosages and support therapeutic monitoring. Methods This article presents a minimal physiologically based pharmacokinetic (PBPK) model for HDMTX, which specifically accounts for individual characteristics such as body weight, height, gender, age, hematocrit, and serum creatinine to provide individualized predictions. The model supplies a detailed and mechanistic description of capillary and cellular exchanges between plasma, interstitial fluid, and intracellular fluid compartments, and focuses on an individualized description of renal excretion. Results The minimal PBPK model is identified and validated with a literature dataset based on Chinese patients suffering from primary central nervous system lymphoma. A comparison with a pharmacokinetic model from the literature suggests that the proposed model provides improved predictions. Remarkably, the model does not present any significant bias in a wide range of degrees of renal function. Conclusion Results show that model predictions can capture the wide intra- and inter-individual variability of HDMTX, and highlight the role played by the individual degree of renal function. The proposed model can be the basis for the development of clinical decision-support systems for individualized dosages and therapeutic monitoring.
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Affiliation(s)
- Giuseppe Pesenti
- PSE-Lab, Process Systems Engineering Laboratory, Dipartimento di Chimica, Materiali e Ingegneria Chimica "Giulio Natta", Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milano, Italy
| | - Marco Foppoli
- Unit of Lymphoid Malignancies, Division of Onco-Hematological Medicine, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy
| | - Davide Manca
- PSE-Lab, Process Systems Engineering Laboratory, Dipartimento di Chimica, Materiali e Ingegneria Chimica "Giulio Natta", Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milano, Italy.
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15
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Zarou MM, Vazquez A, Vignir Helgason G. Folate metabolism: a re-emerging therapeutic target in haematological cancers. Leukemia 2021; 35:1539-1551. [PMID: 33707653 PMCID: PMC8179844 DOI: 10.1038/s41375-021-01189-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 01/13/2021] [Accepted: 02/02/2021] [Indexed: 01/31/2023]
Abstract
Folate-mediated one carbon (1C) metabolism supports a series of processes that are essential for the cell. Through a number of interlinked reactions happening in the cytosol and mitochondria of the cell, folate metabolism contributes to de novo purine and thymidylate synthesis, to the methionine cycle and redox defence. Targeting the folate metabolism gave rise to modern chemotherapy, through the introduction of antifolates to treat paediatric leukaemia. Since then, antifolates, such as methotrexate and pralatrexate have been used to treat a series of blood cancers in clinic. However, traditional antifolates have many deleterious side effects in normal proliferating tissue, highlighting the urgent need for novel strategies to more selectively target 1C metabolism. Notably, mitochondrial 1C enzymes have been shown to be significantly upregulated in various cancers, making them attractive targets for the development of new chemotherapeutic agents. In this article, we present a detailed overview of folate-mediated 1C metabolism, its importance on cellular level and discuss how targeting folate metabolism has been exploited in blood cancers. Additionally, we explore possible therapeutic strategies that could overcome the limitations of traditional antifolates.
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Affiliation(s)
- Martha M Zarou
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
- Cancer Research UK Beatson Institute, Glasgow, UK
| | - Alexei Vazquez
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK.
- Cancer Research UK Beatson Institute, Glasgow, UK.
| | - G Vignir Helgason
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK.
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16
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Berlin C, Lange K, Lekaye HC, Hopland K, Phillips S, Piao J, Tabar V. Long-term clinically relevant rodent model of methotrexate-induced cognitive impairment. Neuro Oncol 2021; 22:1126-1137. [PMID: 32242229 DOI: 10.1093/neuonc/noaa086] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND With the enhanced use of chemotherapy and the advent of increased patient survival rates, there are an increasing number of cancer survivors living with chemotherapy-induced cognitive impairment. A growing number of clinical studies have brought to light the association of agents like methotrexate in generating these neurological sequelae, although mechanisms remain unclear. METHODS Here, we use a clinically relevant regimen of several cycles of methotrexate and leucovorin rescue to develop a model of chemotherapy-induced cognitive impairment, and investigate the in vivo long-term (16 mo) impact of high-dose systemic methotrexate on white matter cellular dynamics as assessed by stereology, animal behavior, and diffusion tensor imaging. RESULTS Our results indicate that at 6 and 16 months post-chemotherapy, methotrexate-treated rats exhibit a significant and permanent decrease in the number of oligodendrocytes and their progenitors in the white matter, in corpus callosum volumes, and myelin basic protein. These findings are associated with mostly delayed deficits in performance on Morris Water Maze and Novel Object Recognition tasks. Diffusion tensor imaging demonstrates significantly decreased fractional anisotropy values in the callosum genu, body, and splenium, as well as previously unassessed areas like the fimbria. Interestingly, these white matter changes are preceded by an earlier, transient decrement in white matter microglia at 3 months, and hippocampal neural progenitors at 3 and 6 months. CONCLUSION These results demonstrate a significant negative impact of methotrexate on the oligodendrocyte compartment and white matter, associated with cognitive impairment. The data also support the use of diffusion tensor imaging in monitoring white matter integrity in this context.
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Affiliation(s)
- Connor Berlin
- Downstate Medical Center, College of Medicine, State University of New York, Brooklyn, New York
| | - Katharine Lange
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - H Carl Lekaye
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kelsey Hopland
- Neuroscience Graduate Program, Weill Cornell Medicine, New York, New York
| | - Samantha Phillips
- Weill Cornell/Rockefeller/Sloan Kettering Tri-Institutional MD-PhD Program, New York, New York
| | - Jinghua Piao
- Department of Neurosurgery and Center for Stem Cell Biology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane Tabar
- Department of Neurosurgery and Center for Stem Cell Biology, Memorial Sloan Kettering Cancer Center, New York, New York
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17
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Huang S, Jin L, Yang J, Duan LY, Zhang M, Zhou JC, Zhang HY. Study on Relationships of Tumor Status and Gene Polymorphism With Blood Concentration of MTX and Toxicities in 63 Pediatric Mature B Cell Lymphoma in Chinese Population. Technol Cancer Res Treat 2021; 20:1533033821995288. [PMID: 33752528 PMCID: PMC8010844 DOI: 10.1177/1533033821995288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This study investigated the relationships of tumor status (stage, renal involvement, bone marrow status, bulky disease, liver function), tumor gene polymorphism, and methotrexate (MTX) dosage (stratified by treatment group) with blood MTX levels and adverse reactions (ADR). METHODS We retrospectively reviewed 63 mature B cell lymphoma patients who were treated in our center. Genotyping of the MTHFR 677 and SLCO1B1 genes was carried out, and the relationships between tumor status, polymorphism of the genes, MTX level, and ADR were analyzed. RESULTS Altogether, 63 children were included. The mean blood MTX concentration was 0.25 ± 0.2 umol/L at 45 h. Liver dysfunction and bulky disease were both correlated with MTX level (both P < 0.05). ADRs were higher among patients with blood MTX > 0.5 mmol/l at 45 h than for the groups with lower blood MTX. The MTHFR 677 CT genotype was correlated with liver function damage (P = 0.04); the rs11045879 locus CC genotype of SLCO1B1, stage IV, and bulky disease at the time of diagnosis were correlated with 4° neutropenia (P < 0.05). Stage IV, bulky disease, leukemia stage at the time of diagnosis, and C2 treatment group were correlated with severe anemia (P < 0.05). Stage IV, bulky disease, leukemia stage, renal invasion at the time of diagnosis, and C2 treatment group were associated with severe thrombocytopenia (P < 0.05). Bulky disease and renal invasion at the time of diagnosis were associated with severe mucositis and severe infection (P < 0.05). CONCLUSION Taken together, our data demonstrate that gene polymorphism, MTX levels, tumor status, and treatment group might be useful to optimize MTX therapy and estimate toxicity.
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Affiliation(s)
- Shuang Huang
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Discipline of Pediatrics, Ministry of Education, MOE Key Laboratory of Major Diseases in Children, Hematology Oncology Center, Beijing, China
| | - Lin Jin
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Discipline of Pediatrics, Ministry of Education, MOE Key Laboratory of Major Diseases in Children, Hematology Oncology Center, Beijing, China
| | - Jing Yang
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Discipline of Pediatrics, Ministry of Education, MOE Key Laboratory of Major Diseases in Children, Hematology Oncology Center, Beijing, China
| | - Long Yan Duan
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Discipline of Pediatrics, Ministry of Education, MOE Key Laboratory of Major Diseases in Children, Hematology Oncology Center, Beijing, China
| | - Meng Zhang
- Beijing Key Laboratory of Pediatric Hematology Oncology, National Discipline of Pediatrics, Ministry of Education, MOE Key Laboratory of Major Diseases in Children, Hematology Oncology Center, Beijing, China
| | - Ju Chun Zhou
- Pathology Department, 117984Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Hong Yong Zhang
- Pathology Department, 117984Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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18
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DeFino CE, Barreto JN, Pawlenty AG, Ruff MW, Carabenciov ID, Mara KC, Thompson CA. Lack of drug interaction between levetiracetam and high-dose methotrexate in patients with lymphoma. Pharmacotherapy 2021; 41:430-439. [PMID: 33655525 DOI: 10.1002/phar.2516] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/24/2021] [Accepted: 02/02/2021] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE To determine whether there is a drug-drug interaction precluding the concomitant use of levetiracetam and high-dose methotrexate (HDMTX). DESIGN Retrospective analysis. SETTING Large academic tertiary care medical center. PATIENTS Adult lymphoma patients who received HDMTX as a 4-h infusion with or without concomitant levetiracetam. MEASUREMENTS AND MAIN RESULTS Generalized estimating equations clustered on patient were used to assess each outcome. The primary outcome was the incidence of delayed MTX elimination (MTX level >1 µmol/L at 48 h). Secondary outcomes included incidence of acute kidney injury (AKI) and hospital length of stay (LOS). The 430 included patients receiving 1993 doses of HDMTX had a median (IQR) age of 66 (57.5, 72.6) years, 88 (20.5%) received concomitant levetiracetam with at least one dose of MTX, 267 (62.1%) were male, and 397 (92.3%) were Caucasian. HDMTX doses ranged from 1 to 8 g/m2 . The most common lymphoma diagnoses were systemic diffuse large B-cell lymphoma (DLBCL; 58.5%) and systemic DLBCL with central nervous system (CNS) involvement (32.8%). Rates of delayed elimination with and without levetiracetam were 13.4% and 16.3%, respectively (OR = 0.80, 95% CI 0.47-1.34, p = 0.39). AKI occurred in 15.6% and 17.0% of patients with and without concomitant levetiracetam, respectively (OR = 0.83, 95% CI 0.52-1.33, p = 0.28). The median LOS with and without levetiracetam was 4.2 and 4.1 days, respectively (p = 0.039). On multivariable analyses, only age, body surface area, diagnosis of systemic DLBCL with CNS involvement, serum creatinine, hemoglobin, total bilirubin, and dose of HDMTX were associated with delayed elimination. CONCLUSIONS High-dose methotrexate administered with concomitant levetiracetam was not associated with increased risk for delayed MTX elimination or AKI. These results support that levetiracetam and HDMTX are safe for coadministration.
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Affiliation(s)
| | - Jason N Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Michael W Ruff
- Division of Neuro-Oncology, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ivan D Carabenciov
- Division of Neurocritical Care, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Carrie A Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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19
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Nayak RR, Alexander M, Deshpande I, Stapleton-Gray K, Rimal B, Patterson AD, Ubeda C, Scher JU, Turnbaugh PJ. Methotrexate impacts conserved pathways in diverse human gut bacteria leading to decreased host immune activation. Cell Host Microbe 2021; 29:362-377.e11. [PMID: 33440172 PMCID: PMC7954989 DOI: 10.1016/j.chom.2020.12.008] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/24/2020] [Accepted: 12/08/2020] [Indexed: 02/07/2023]
Abstract
Immunomodulatory drugs can inhibit bacterial growth, yet their mechanism of action, spectrum, and clinical relevance remain unknown. Methotrexate (MTX), a first-line rheumatoid arthritis (RA) treatment, inhibits mammalian dihydrofolate reductase (DHFR), but whether it directly impacts gut bacteria is unclear. We show that MTX broadly alters the human gut microbiota. Drug sensitivity varied across strains, but the mechanism of action against DHFR appears conserved between mammalian and bacterial cells. RA patient microbiotas were sensitive to MTX, and changes in gut bacterial taxa and gene family abundance were distinct between responders and non-responders. Transplantation of post-treatment samples into germ-free mice given an inflammatory trigger led to reduced immune activation relative to pre-treatment controls, enabling identification of MTX-modulated bacterial taxa associated with intestinal and splenic immune cells. Thus, conservation in cellular pathways across domains of life can result in broad off-target drug effects on the human gut microbiota with consequences for immune function.
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Affiliation(s)
- Renuka R Nayak
- Rheumatology Division, Department of Medicine, University of California, San Francisco, CA 94143, USA; Department of Microbiology & Immunology, University of California, San Francisco, CA 94143, USA
| | - Margaret Alexander
- Department of Microbiology & Immunology, University of California, San Francisco, CA 94143, USA
| | - Ishani Deshpande
- Department of Microbiology & Immunology, University of California, San Francisco, CA 94143, USA
| | - Kye Stapleton-Gray
- Department of Microbiology & Immunology, University of California, San Francisco, CA 94143, USA
| | - Bipin Rimal
- Department of Veterinary and Biomedical Sciences, Pennsylvania State University, University Park, PA 16802, USA
| | - Andrew D Patterson
- Department of Veterinary and Biomedical Sciences, Pennsylvania State University, University Park, PA 16802, USA
| | - Carles Ubeda
- Centro Superior de Investigación en Salud Pública - FISABIO, Valencia, Spain; CIBER en Epidemiología y Salud Pública, Madrid, Spain
| | - Jose U Scher
- Department of Medicine, New York University, New York, NY 10003, USA
| | - Peter J Turnbaugh
- Department of Microbiology & Immunology, University of California, San Francisco, CA 94143, USA; Chan Zuckerberg Biohub, San Francisco, CA 94158, USA.
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20
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A pharmacologically-based approach to high dose methotrexate administration to investigate nephrotoxicity and acute kidney injury biomarkers in children and adolescents with newly diagnosed osteosarcoma. Cancer Chemother Pharmacol 2021; 87:807-815. [PMID: 33677616 DOI: 10.1007/s00280-021-04248-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/11/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE High dose methotrexate (HDMTX) acute kidney injury (AKI) results in prolonged hospitalization and treatment delays. Using a pharmacologically-based approach, HDMTX was administered with standard combination therapy to patients with osteosarcoma; nephrotoxicity was assessed. METHODS Patients were randomized by cycle to 4 h or 12 h HDMTX (12 g/m2) infusions administered with hydration, alkalization and leucovorin rescue. Urinalysis, AKI biomarkers, and estimated glomerular filtration rate using serum creatinine or cystatin C (GFRCr or GFRcysC) were obtained. Serum and urine methotrexate concentrations [MTX] were measured. RESULTS Patients (n = 12), median (range) age 12.4 (5.7-19.2) years were enrolled; 73 MTX infusions were analyzed. Median (95% Confidence Interval) serum and urine [MTX] were 1309 (1190, 1400) µM and 16.4 (14.7, 19.4) mM at the end of 4 h infusion and 557 (493, 586) µM and 11.1 (9.9, 21.1) mM at the end of 12 h infusion. Time to serum [MTX] < 0.1 µM was 83 (80.7, 90.7) h and 87 (82.8, 92.4) h for 4 and 12 h infusions. GFRCr was highly variable, increased after cisplatin, and exceeded 150 ml/min/1.73 m2. GFRcysC was less variable and decreased at the end of therapy. AKI biomarkers were elevated indicating acute tubular dysfunction, however, did not differ between 4 and 12 h infusions. Radiographic and histological response were similar for patients receiving 4 h or 12 h infusions; the median percent tumor necrosis was > 95%. CONCLUSIONS Reducing peak serum and urine MTX concentration by prolonging the infusion duration did not alter risk of acute kidney injury. GFRcysC was decreased at the end of therapy. Proteinuria and elevations in AKI biomarkers indicate that direct tubular damage contributes to HDMTX nephrotoxicity. CLINICAL TRIAL NCT01848457.
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21
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Studies on the intracellular accumulation process of methotrexate and its correlation with the key protein using an LC-MS/MS method: a novel way to realize prospective individualized medication. Anal Bioanal Chem 2021; 413:1799-1807. [PMID: 33564926 DOI: 10.1007/s00216-020-03125-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/08/2020] [Accepted: 12/14/2020] [Indexed: 10/22/2022]
Abstract
High-dose methotrexate (HDMTX) combined with leucovorin (LV) is the first-line drug therapy for many kinds of malignant tumors. However, the specific treatment plans, such as dosage and duration of administration, are usually formulated according to the clinician's experience and therapeutic drug monitoring (TDM) of methotrexate in patients' plasma, which are responsible for strong individual differences of drug usage. A large number of studies have shown that methotrexate targets the inside of the cell. The key cytotoxic component is the methotrexate polyglutamates (MTXPGs) in the cell. The concentration of methotrexate in plasma does not reflect the efficacy and side effects well. Based on mass spectrometry technology, we developed and validated an accurate, sensitive, and stable method to quantify the intracellular MTX (MTXPG1) and its metabolites MTXPG2-7 simultaneously. The lower limit of quantification was 0.100 ng/ml, and the run time was only 3 min. Moreover, our team has already developed two LC-MS/MS-based methods to respectively quantify methotrexate in plasma samples and two key proteins (γ-glutamyl hydrolase [GGH] and folylpolyglutamate synthetase [FPGS]) in peripheral blood mononuclear cells (PBMC). Through these highly sensitive and accurate approaches, we have gained a deep understanding of the whole pharmacokinetic process of MTX and explored the key factors affecting the accumulation process of intracellular active components (MTXPGs). Based on this research, it is possible to find a more effective way to provide an accurate reference for clinical drug use than traditional therapeutic drug monitoring (TDM).
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22
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Inoue A, Ohmuro-Matsuyama Y, Kitaguchi T, Ueda H. Creation of a Nanobody-Based Fluorescent Immunosensor Mini Q-body for Rapid Signal-On Detection of Small Hapten Methotrexate. ACS Sens 2020; 5:3457-3464. [PMID: 33169966 DOI: 10.1021/acssensors.0c01404] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
"Quenchbody (Q-body)" is a quench-based fluorescent biosensor labeled with a fluorescent dye near the antigen-binding site of an antibody. Q-bodies can detect a range of target molecules quickly by simply mixing with a sample. However, the development of Q-bodies using VHH-nanobodies derived from camelid heavy-chain antibodies has not been reported despite their favorable characteristics. Here, we report a "mini Q-body" that can detect the chemotherapy agent methotrexate (MTX) by using anti-MTX nanobody. Three kinds of constructs each encoding an N-terminal Cys-tag and anti-MTX VHH gene with a different length of linker (GGGS)n (n = 0, 2, and 4) between them were prepared followed by the expression in Escherichia coli and labeling with several dye maleimides. When the fluorescence intensities in the presence of varied MTX concentrations were measured, TAMRA-labeled nanobodies showed a higher response than ATTO520- or R6G-labeled ones. Especially, TAMRA C6-labeled mini Q-body with no linker showed the highest response of ∼6-fold and a low detection limit of 0.56 nM. When each Trp residue in the mini Q-body was mutated to address the quenching mechanism, the major role of Trp34 at CDR1 in quenching was revealed. Furthermore, the mini Q-body could detect MTX in 50% human serum with a low detection limit of 1.72 nM, showing its applicability to therapeutic drug monitoring. This study is expected to become the basis of the construction of highly responsive mini Q-bodies for sensitive detection of many molecules from small haptens to larger proteins, which will lead to broader applications such as point-of-care tests.
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Affiliation(s)
- Akihito Inoue
- School of Life Science and Technology, Tokyo Institute of Technology, Nagatsuta-cho, Yokohama, Kanagawa 226-8503, Japan
| | - Yuki Ohmuro-Matsuyama
- Laboratory for Chemistry and Life Science, Institute of Innovative Research, Tokyo Institute of Technology, Nagatsuta-cho, Yokohama, Kanagawa 226-8503, Japan
| | - Tetsuya Kitaguchi
- Laboratory for Chemistry and Life Science, Institute of Innovative Research, Tokyo Institute of Technology, Nagatsuta-cho, Yokohama, Kanagawa 226-8503, Japan
| | - Hiroshi Ueda
- Laboratory for Chemistry and Life Science, Institute of Innovative Research, Tokyo Institute of Technology, Nagatsuta-cho, Yokohama, Kanagawa 226-8503, Japan
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23
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King LD, Sia H, Anoopkumar‐Dukie S. Trimethoprim‐sulfamethoxazole as
Pneumocystis jiroveci
pneumonia prevention in patients undergoing methotrexate therapy for hematological malignancies: A review of the literature. Hematol Oncol 2020. [DOI: 10.1002/hon.2823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Liam D. King
- Ramsay Pharmacy John Flynn Private Hospital Tugun Queensland Australia
- School of Pharmacy and Pharmacology Griffith University Southport Queensland Australia
| | - Hanlon Sia
- First in Haematology and Oncology Pindara Private Hospital Benowa Queensland Australia
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DMARDs-Gut Microbiota Feedback: Implications in the Response to Therapy. Biomolecules 2020; 10:biom10111479. [PMID: 33114390 PMCID: PMC7692063 DOI: 10.3390/biom10111479] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/10/2020] [Accepted: 10/21/2020] [Indexed: 12/20/2022] Open
Abstract
Due to its immunomodulatory effects and the limitation in the radiological damage progression, disease-modifying antirheumatic drugs (DMARDs) work as first-line rheumatoid arthritis (RA) treatment. In recent years, numerous research projects have suggested that the metabolism of DMARDs could have a role in gut dysbiosis, which indicates that the microbiota variability could modify the employment of direct and indirect mechanisms in the response to treatment. The main objective of this review was to understand the gut microbiota bacterial variability in patients with RA, pre and post-treatment with DMARDs, and to identify the possible mechanisms through which microbiota can regulate the response to pharmacological therapy.
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25
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Mangum R, Bernhardt MB, Cheng WS, Schafer ES, Berg SL, Foster JH. Do intravenous fluid substitutions influence methotrexate clearance? An unanticipated impact of an intravenous sodium bicarbonate drug shortage. Pediatr Blood Cancer 2020; 67:e28334. [PMID: 32608575 DOI: 10.1002/pbc.28334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND National drug shortages of essential medications for childhood cancer have increasingly posed a challenge in the treatment of patients. The efficacy of standardized supportive care practices to avoid treatment-related toxicities may be limited during these drug shortages. High-dose methotrexate (HDMTX) plays a critical role in modern treatment protocols for acute lymphoblastic leukemia and requires stringent supportive care measures to mitigate toxicity. As the result of a national intravenous (IV) sodium bicarbonate shortage, institutional standard HDMTX supportive care guidelines had to be modified. We describe the unanticipated consequences on HDMTX clearance. METHODS We performed a retrospective chart review assessing the impact of alternative compositions of IV fluids on the mean 24-h methotrexate levels (Cpss ) of 25 patients receiving 76 total HDMTX infusions at Texas Children's Hospital Cancer Center from March to October 2017. During the sodium bicarbonate drug shortage, all patients received IV hydration consisting of either dextrose 5%, 0.45% normal saline (D5 ½ NS-Group A) or dextrose 5%, 0.2% normal saline (D5 ¼ NS-Group B). RESULTS Patients receiving a higher total sodium dose demonstrated significantly lower Cpss (25.36 ± 16.6 μMol) compared to patients receiving less sodium (53.9 ± 37.9 μMol; P < .001). CONCLUSIONS Our report shows that in the setting of IV sodium bicarbonate shortage, the composition of hydration IV fluids may affect methotrexate clearance. Patient who received a higher sodium load had a lower 24-h methotrexate level. This demonstrates the potential for unanticipated outcomes resulting from national drug shortages.
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Affiliation(s)
- Ross Mangum
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - M Brooke Bernhardt
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - W Susan Cheng
- Department of Public Heath, Benedictine University, Lisle, Illinois
| | - Eric S Schafer
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - Stacey L Berg
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - Jennifer H Foster
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
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Hurkmans EGE, Klumpers MJ, Vermeulen SH, Hagleitner MM, Flucke U, Schreuder HWB, Gelderblom H, Bras J, Guchelaar HJ, Coenen MJH, Te Loo DMWM. Analysis of Drug Metabolizing Gene Panel in Osteosarcoma Patients Identifies Association Between Variants in SULT1E1, CYP2B6 and CYP4F8 and Methotrexate Levels and Toxicities. Front Pharmacol 2020; 11:1241. [PMID: 32903464 PMCID: PMC7435008 DOI: 10.3389/fphar.2020.01241] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/29/2020] [Indexed: 12/31/2022] Open
Abstract
High-dose methotrexate is a cornerstone agent in the chemotherapeutic treatment of patients with osteosarcoma. However, patients often develop methotrexate-induced toxicities. We aim to identify determinants of methotrexate-induced toxicities in osteosarcoma patients by investigating the relation between drug plasma levels, methotrexate-induced toxicities, and germline variants in genes related to drug absorption, distribution, metabolism, and elimination. A cohort of 114 osteosarcoma patients was genotyped for 1,931 variants in 231 genes using the Drug Metabolism Enzymes and Transporters Plus array. Methotrexate plasma levels and laboratory measurements during and after high-dose methotrexate treatment concerning renal function, liver damage, and myelopoiesis to reflect toxicity outcomes were obtained. One hundred and thirteen patients and a subset of 545 variants in 176 genes passed quality control checks. Methotrexate plasma levels showed associations with creatinine, alanine aminotransferase, and hemoglobin. Genetic variant rs3736599 in the 5'-untranslated region of SULT1E1 was associated with lower 48 hour methotrexate plasma levels [coef -0.313 (95% CI -0.459 - -0.167); p = 2.60 × 10-5]. Association with methotrexate-induced decreased thrombocyte counts was found for two intronic variants in CYP2B6 {rs4803418 [coef -0.187 (95% CI -0.275 - -0.099); p = 3.04 × 10-5] and rs4803419 [coef -0.186 (95% CI -0.278 - -0.093); p = 8.80 × 10-5]}. An association with increased thrombocyte counts was identified for the intronic variant rs4808326 in CYP4F8 [coef 0.193 (95% CI 0.099 - 0.287); p = 6.02 × 10-5]. Moreover, a secondary analysis with a binary approach using CTCAE toxicity criteria resulted in a nominal significant associations (p < 0.05) for two out of three variants (rs4803418 and rs4808326). This is the first study to identify genetic variants in SULT1E1, CYP2B6, and CYP4F8 to be associated with methotrexate pharmacokinetics and toxicities. Validation of these variants in an independent cohort and further functional investigation of variants in the identified genes is needed to determine if and how they affect methotrexate plasma levels and the development of methotrexate-induced toxicities.
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Affiliation(s)
- Evelien G E Hurkmans
- Department of Human Genetics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Marije J Klumpers
- Department of Pediatrics, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Sita H Vermeulen
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Uta Flucke
- Department of Pathology, Radboud University Medical Center, Nijmegen, Netherlands
| | - H W Bart Schreuder
- Department of Orthopedic Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hans Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Leiden, Netherlands
| | - Johannes Bras
- Department of Pathology, Academic Medical Center, Amsterdam, Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Marieke J H Coenen
- Department of Human Genetics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - D Maroeska W M Te Loo
- Department of Pediatrics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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27
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Peng C, Li X, Huang H, Liu T, Wang Z, Fang X, Hong H, Li F, Ren Q, Liu S, Tian Y, Lin T. A prospective, crossover randomized trial of the optimal timing for leucovorin rescue after high-dose methotrexate management in adult non-Hodgkin's lymphoma patients. Leuk Lymphoma 2020; 61:1842-1849. [PMID: 32316801 DOI: 10.1080/10428194.2020.1747061] [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] [Indexed: 10/24/2022]
Abstract
This study aimed to investigate the optimal time of leucovorin rescue for HDMTX in non-Hodgkin's lymphoma (NHL) patients. Ninety-eight patients treated with HDMTX were randomly assigned to receive leucovorin at either 18 or 24 h after initiation of HDMTX infusion during the first cycle and switched to the other mode in the second cycle. All courses achieved an efficacious MTX concentration. Compared to the 18th hour group, the 24th hour group exhibited an increase in incidence of thrombocytopenia (48% versus 34.7%, p = .036) and grade III/IV neutropenia (34.7% versus 21.4%, p = .039). No bleeding occurred and the incidence of fever with grade III/IV neutropenia was low with no difference observed between the two groups. We recommend that with the HDMTX generally used most adult patients with NHL may have greater therapeutic benefit and acceptable toxicity with their LV rescue started at 24 h instead of 18 h.
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Affiliation(s)
- Chen Peng
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xueying Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China.,Department of Medical Oncology, The Seventh Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - He Huang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Tingzhi Liu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China.,Gastrointestinal Institute, Department of Medical Hematology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhao Wang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiaojie Fang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Huangming Hong
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Fangfang Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Quanguang Ren
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shu Liu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Ying Tian
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Tongyu Lin
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
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28
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Amitai I, Rozovski U, El-Saleh R, Shimony S, Shepshelovich D, Rozen-Zvi B, Raanani P, Gafter-Gvili A, Gurion R. Risk factors for high-dose methotrexate associated acute kidney injury in patients with hematological malignancies. Hematol Oncol 2020; 38:584-588. [PMID: 32506594 DOI: 10.1002/hon.2759] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 05/12/2020] [Accepted: 05/26/2020] [Indexed: 12/29/2022]
Abstract
High dose methotrexate (HDMTX)-induced acute kidney injury (AKI) is a well-known adverse event in hemato-oncology patients. Our purpose was to define factors and setup cut-offs that may help better identify patients at-risk for developing AKI following HDMTX. All consecutive patients who received MTX dose ≥1 g were retrospectively reviewed. We compared patients with or without renal toxicity. We used a logistic regression model to define baseline variables associated with AKI. Overall survival (OS) was estimated by the Kaplan-Meier method employing log-rank test. Between 2012 and 2017, 160 patients were included with a total of 265 courses. Indications included: primary central nervous system (CNS) lymphoma, CNS prophylaxis in other lymphoma types, acute lymphatic leukemia and others. Median age at diagnosis was 58 years (range, 18-84), 54% were males, median MTX dose was 1941 mg/m2 (range, 743-5442) and AKI developed in 9% of drug administrations (n = 24). In univariate analysis: age > 40, LDH > 380 units/L, eGFR < 112 mL/min, albumin <3.6 mg/dL at baseline and Charlson comorbidity index (CCI) were associated with AKI. In multivariable analysis, only LDH > 380 units/L (OR = 4.1, 95% confidence interval [CI] 1.04-20.9, P = .04) and albumin levels <3.6 g/dL (OR = 4.17, 95% CI 1.04-6.5, P = .04) remained significant. In patients with AKI, median drug elimination was longer (8 days vs 5 days). In 80% of cases, the creatinine levels returned to normal within 1 month. Yet, the median survival of patients who developed AKI was 37 months, compared to 145 months in patients without AKI (Log rank = 0.015). In conclusion, LDH > 380 units/L and albumin <3.6 g/dL were the strongest factors associated with AKI in patients receiving HDMTX. Although the rise in creatinine levels was almost uniformly reversible, AKI was associated with increased mortality rates.
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Affiliation(s)
- Irina Amitai
- Odette Cancer Center, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Rozovski
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Reem El-Saleh
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shai Shimony
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Daniel Shepshelovich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Medicine I, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Benaya Rozen-Zvi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva, Israel
| | - Pia Raanani
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Anat Gafter-Gvili
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel.,Department of Internal Medicine A, Rabin Medical Center, Petah Tikva, Israel
| | - Ronit Gurion
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
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29
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Mohammad Jafari R, Ala M, Goodarzi N, Dehpour AR. Does Pharmacodynamics of Drugs Change After Presenting them as Nanoparticles Like their Pharmacokinetics? Curr Drug Targets 2020; 21:807-818. [DOI: 10.2174/1389450121666200128113547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/01/2019] [Accepted: 12/02/2019] [Indexed: 12/21/2022]
Abstract
:
Nowadays, the breakthrough in different medical branches makes it feasible to designate
new methods of drug delivery to achieve the most cost-effective and the least unpleasant consequenceimposing
solutions to overcome a wide range of diseases.
:
Nanoparticle (NP) drugs entered the therapeutic system, especially in cancer chemotherapy. These
drugs are quite well-known for two traits of being long-acting and less toxic. For a long time, it has
been investigated how NPs will change the kinetics of drugs. However, there are a few studies that inclined
their attention to how NPs affect the dynamics of drugs. In this review, the latter point will
mainly be discussed in an example-based manner. Besides, other particular features of NPs will be
briefly noted.
:
NPs are capable of affecting the biologic system as much as a drug. Moreover, NPs could arise a wide
variety of effects by triggering their own receptors. NPs are able to change a receptor function and
manipulate its downstream signaling cascade.
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Affiliation(s)
- Razieh Mohammad Jafari
- Experimental Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Moein Ala
- Experimental Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Navid Goodarzi
- Nanotechnology Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Reza Dehpour
- Experimental Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
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30
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Chen AR, Wang YM, Lin M, Kuo DJ. High-Dose Methotrexate in Pediatric Acute Lymphoblastic Leukemia: Predictors of Delayed Clearance and the Effect of Increased Hydration Rate on Methotrexate Clearance. Cureus 2020; 12:e8674. [PMID: 32699674 PMCID: PMC7370657 DOI: 10.7759/cureus.8674] [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] [Indexed: 11/05/2022] Open
Abstract
Objectives High-dose methotrexate (HDMTX) is an important chemotherapeutic agent in the treatment of many cancers. Identification of the predictors of poor clearance during HDMTX infusions could advance the introduction of improved supportive care to prevent toxicities and reduce hospital length of stay. The purpose of this study was to identify relationships between patient physical characteristics and HDMTX clearance in the treatment of pediatric acute lymphoblastic leukemia (ALL). At our hospital, patients who have delayed methotrexate (MTX) clearance during a cycle of HDMTX receive an increased rate of hydration with subsequent cycles. This increase in hydration rate was examined for its potential to mitigate predictors of poor clearance and to prevent nephrotoxicity. Methods This study retrospectively examined the treatment records of 87 pediatric patients diagnosed with ALL who were treated on or according to Children's Oncology Group (COG) protocols AALL0232, AALL0434, AALL1131, and AALL1231. Each patient received four cycles of HDMTX (5 g/m2 over 24 hours) at two-week intervals. Patients received either 125 ml/m2/hour (standard) or 200 ml/m2/hour (delayed clearance protocol) hydration before, with, and after each infusion. MTX levels taken at 24-, 42-, and 48-hour time points were used as an indirect measure of drug clearance. Two-tailed inference for ordinary least squares regression and both heteroskedastic and paired two-tailed t-tests were performed to identify physical characteristics associated with delayed MTX clearance and the effects of hydration rate on MTX clearance, respectively. Results Patient age and body surface area (BSA) were found to have statistically significant (p<0.05) positive associations with the serum MTX levels at 24, 42, and 48 hours in cycle 1. Age and BSA were significant only at the 24-hour time point in cycles 2 and 4. Weight alone was not associated with delayed MTX clearance. For patients who had delayed MTX clearance once and thus received the delayed clearance protocol in subsequent cycles, increasing the hydration rate from 125 to 200 ml/m2/hour was associated with a statistically significant decrease in average MTX levels as well as serum creatinine levels at the 24-, 42-, and 48-hour time points. Once patients with delayed clearance received the 200 ml/m2/hour rate of hydration, the history of prior poor clearance lost its predictive value for serum MTX levels and delayed clearance. Conclusions These results suggest that patient age and BSA are significant predictors of MTX clearance if all patients receive the same rate of hydration. Age and BSA affect the distribution phase of MTX kinetics, with downstream effects in the elimination phase. Increased hydration mitigates the effects of these physical characteristics on the elimination phase kinetics by improving renal elimination of MTX, causing a loss of significance of age and BSA as predictors of MTX levels in subsequent cycles at the 42- and 48-hour time points, but with less effect at 24 hours. Thus, hyperhydration regimens prior to cycle 1 of HDMTX could be considered for patients presenting with risk factors of advanced age or high BSA to avoid delayed clearance.
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Affiliation(s)
- Aaron R Chen
- Division of Biological Sciences, University of California San Diego, San Diego, USA
| | - YunZu M Wang
- Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Mark Lin
- Department of Pharmacy, University of California San Francisco Benioff Children's Hospital, Oakland, USA
| | - Dennis J Kuo
- Pediatric Hematology/Oncology, University of California San Diego, San Diego, USA
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31
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Young EP, Cheng WS, Bernhardt MB, Wang LL, Rainusso N, Foster JH. Risk factors associated with delayed methotrexate clearance and increased toxicity in pediatric patients with osteosarcoma. Pediatr Blood Cancer 2020; 67:e28123. [PMID: 31867853 DOI: 10.1002/pbc.28123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/18/2019] [Accepted: 11/24/2019] [Indexed: 11/08/2022]
Abstract
High-dose methotrexate (HD-MTX; 12 g/m2 ) is part of standard therapy for pediatric osteosarcoma (OS). Risk factors associated with MTX toxicity in children with OS are not well defined. We investigated the association between peak MTX levels (four-hour) and delayed MTX clearance or treatment toxicity. Information was retrieved from electronic medical records of 33 OS patients treated with HD-MTX at Texas Children's Hospital from 2008 to 2015. We found that the four-hour MTX level did not contribute to toxicity or delayed MTX clearance. We demonstrated that certain demographic characteristics are associated with delayed clearance and increased toxicity.
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Affiliation(s)
- Elizabeth P Young
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | | | | | - Lisa L Wang
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Nino Rainusso
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Jennifer H Foster
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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32
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Young A, Beriault D, Jung B, Nikonova A, Abosh D, Lee S, Zaltzman J, Perl J. DAMPAned Methotrexate: A Case Report and Review of the Management of Acute Methotrexate Toxicity. Can J Kidney Health Dis 2020; 6:2054358119895078. [PMID: 31903191 PMCID: PMC6926974 DOI: 10.1177/2054358119895078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/06/2019] [Indexed: 11/16/2022] Open
Abstract
Rationale Consensus guidelines on the management of methotrexate-induced nephrotoxicity using glucarpidase (Voraxaze) may be relatively unfamiliar to the nephrology community. Presenting concerns of the patient A 61-year-old man with intravascular large B-cell lymphoma was admitted for cycle #1 of high-dose methotrexate (HDMTX) following 2 cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy. On admission, he was clinically euvolemic and had a creatinine clearance of 98 mL/min. He received standard HDMTX toxicity prophylaxis with volume expansion, urinary alkalinization, and leucovorin rescue. Diagnoses Despite prophylactic efforts, he developed a severe acute kidney injury, creatinine 63 to 226 µmol/L (2.56 mg/dL), following HDMTX, impaired methotrexate clearance, and neurotoxicity manifested by status epilepticus. Interventions He was given glucarpidase to convert extracellular methotrexate into its inactive metabolites, glutamate and DAMPA (4-deoxy-4-amino-N 10-methylpteroic acid) at 52 hours post-HDMTX. Cross-reactivity between commercial methotrexate immunoassays with DAMPA led to falsely elevated methotrexate concentrations for much longer than expected based on the current guideline (5 days instead of <48 hours). This required ongoing monitoring of methotrexate concentration by mass spectrometry. Outcomes The patient remained nonoliguric and did not develop acute indications for dialysis. Serum creatinine peaked at 608 µmol/L (6.88 mg/dL) 6 days after HDMTX. He ultimately had a full renal and neurologic recovery. Lessons learned Glucarpidase is an effective option for nonrenal elimination of methotrexate-induced nephrotoxicity. Timing of methotrexate concentration monitoring to assess for toxicity, how to access the drug, and the need for ongoing monitoring by mass spectrometry beyond the guideline recommendation are highlighted for centers where HDMTX therapy may be used.
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Affiliation(s)
- Ann Young
- Nephrology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Daniel Beriault
- Department of Laboratory Medicine & Pathobiology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Benjamin Jung
- Department of Laboratory Medicine & Pathobiology, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Anna Nikonova
- Medical Oncology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Dory Abosh
- Medical Oncology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Samantha Lee
- Department of Pharmacy, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Jeff Zaltzman
- Nephrology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Jeffrey Perl
- Nephrology, St. Michael's Hospital, University of Toronto, Ontario, Canada
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33
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Škorić B, Jovanović M, Miljković B, Kuzmanović M, Vučićević K. Clinical pharmacokinetics of methotrexate in the treatment of acute lymphoblastic leukemia and non-Hodgkin lymphoma in pediatric patients. ARHIV ZA FARMACIJU 2020. [DOI: 10.5937/arhfarm2001020x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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34
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Dhanushkodi M. High-dose Methotrexate. Indian J Med Paediatr Oncol 2019. [DOI: 10.4103/ijmpo.ijmpo_157_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AbstractHigh-dose methotrexate (HDMTX) is defined as methotrexate dose of ≥500 mg/m2. It is used in the treatment of acute lymphoblastic leukemia, osteosarcoma, and primary central nervous system lymphoma. Administration mandates adequate hydration; urine alkalinization; leucovorin rescue, monitoring of urine output, serum creatinine, and methotrexate levels. Delayed methotrexate clearance is managed by increasing hydration and leucovorin dose. Glucarpidase is the antidote for patients with renal toxicity. Studies from India have shown that HDMTX can be administered without monitoring of methotrexate levels with strict monitoring of urine pH, urine output, and serum creatinine and extended hydration and leucovorin doses.
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35
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Serum Methotrexate Level and Side Effects of High Dose Methotrexate Infusion in Pediatric Patients with Acute Lymphoblastic Leukaemia (ALL). Indian J Hematol Blood Transfus 2019; 36:51-58. [PMID: 32174691 DOI: 10.1007/s12288-019-01144-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 06/03/2019] [Indexed: 10/26/2022] Open
Abstract
Methotrexate (MTX) is an extensively prescribed antimetabolite especially in the treatment of several pediatric cancers, though managing toxicities associated with methotrexate in high dose continues to be a challenge. A prospective study was carried out from April 2017 to October 2018. Children of either sex below 18 years at the time of enrolment and receiving high dose Methotrexate intravenous infusion over 24 h as a 2 g/m2, 3 g/m2 and 5 g/m2 dose was included in the study. The serum methotrexate level was estimated after the start of 48 h HDMTX infusion by using the ARCHITECT methotrexate assay. Toxicity due to HDMTX was assessed by Common Terminology Criteria for Adverse Events v.5.0. A total of 244 HDMTX infusions were delivered to 62 ALL patients. From the total of 244 cycles, serum methotrexate level in 35 cycles after the start of 48 h HDMTX infusion was found to be ≥ 1.0 μmol/L with reported toxicities among 31 cycles (88.6%). In 209 cycles MTX level was found to be less than 1.0 is statistically significant as compared to other cycles (p < 0.0001). Highest toxicities reported were in cycle I (38.8%). The toxicities such as oral mucositis, neutropenia, the elevation of liver enzymes, dermatological toxicities were found more in cycles whose methotrexate level are greater than 1.0 μmol/L. Dose reduction, increased the length of stay and treatment delay occurred in patients with severe toxicities. Severe toxicities of methotrexate can be interrelated with serum methotrexate levels at 48 h after the start of HDMTX infusion.
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36
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Wang MY, Qu Y, Hu DR, Chen LJ, Shi K, Jia YP, Yi YY, Wei Q, Niu T, Qian ZY. Methotrexate-loaded biodegradable polymeric micelles for lymphoma therapy. Int J Pharm 2019; 557:74-85. [DOI: 10.1016/j.ijpharm.2018.12.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 12/29/2022]
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Hui KH, Chu HM, Fong PS, Cheng WTF, Lam TN. Population Pharmacokinetic Study and Individual Dose Adjustments of High-Dose Methotrexate in Chinese Pediatric Patients With Acute Lymphoblastic Leukemia or Osteosarcoma. J Clin Pharmacol 2018; 59:566-577. [PMID: 30556906 DOI: 10.1002/jcph.1349] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/06/2018] [Indexed: 11/07/2022]
Abstract
High-dose methotrexate (>0.5 g/m2 ) is among the first-line chemotherapeutic agents used in treating acute lymphoblastic leukemia (ALL) and osteosarcoma in children. Despite rapid hydration, leucovorin rescue, and routine therapeutic drug monitoring, severe toxicity is not uncommon. This study aimed at developing population pharmacokinetic (popPK) models of high-dose methotrexate for ALL and osteosarcoma and demonstrating the possibility and convenience of popPK model-based individual dose optimization using R and shiny, which is more accessible, efficient, and clinician-friendly than NONMEM. The final data set consists of 36 ALL (354 observations) and 16 osteosarcoma (585 observations) patients. Covariate model building and parameter estimations were done using NONMEM and Perl-speaks-NONMEM. Diagnostic Plots and bootstrapping validated the models' performance and stability. The dose optimizer developed based on the validated models can obtain identical individual parameter estimates as NONMEM. Compared to calling a NONMEM execution and reading its output, estimating individual parameters within R reduces the execution time from 8.7-12.8 seconds to 0.4-1.0 second. For each subject, the dose optimizer can recommend (1) an individualized optimal dose and (2) an individualized range of doses. For osteosarcoma, recommended optimal doses by the optimizer resemble the final doses at which the subjects were eventually stabilized. The dose optimizers developed demonstrated the potential to inform dose adjustments using a model-based, convenient, and efficient tool for high-dose methotrexate. Although the dose optimizer is not meant to replace clinical judgment, it provides the clinician with the individual pharmacokinetics perspective by recommending the (range of) optimal dose.
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Affiliation(s)
- Ka Ho Hui
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Ho Man Chu
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Pui Shan Fong
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Wai Tsoi Frankie Cheng
- Division of Haematology, Oncology, and Bone Marrow Transplantation, Department of Paediatrics, Prince of Wales Hospital, Hong Kong.,Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong
| | - Tai Ning Lam
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
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Nowak TJ, Lorge AH, Rein LE, Canadeo AM, Frank JP, Samanas LC, Urmanski AM, Atallah EL. Implementation and evaluation of high-dose methotrexate administration guidelines. J Oncol Pharm Pract 2018; 25:1675-1681. [PMID: 30360674 DOI: 10.1177/1078155218808866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND High-dose methotrexate is used to treat a variety of malignancies. Methotrexate-associated supportive care and the threshold methotrexate level for the discontinuation of supportive care are not consistent among studies. We evaluated the implementation of high-dose methotrexate administration guidelines, which raised the standard threshold methotrexate level for the discontinuation of supportive care from <0.05 to <0.1 µmol. METHODS A single-center, observational analysis of patients receiving high-dose methotrexate from 1 January 2015 to 31 May 2017 was conducted. The primary endpoint was time from the start of the methotrexate infusion until the discontinuation of the sodium bicarbonate infusion, before and after guideline implementation. RESULTS Fifty-two patients met the inclusion criteria, which comprised of a total of 136 individual methotrexate doses and were included in the retrospective analysis. Twenty-four patients were included in the prospective analysis, which comprised a total of 46 individual methotrexate doses. The primary endpoint, time until discontinuation of the sodium bicarbonate infusion, was a median of 97.7 h in the retrospective group versus 73.2 h in the prospective group (p = 0.098). Secondary endpoints also favored patients in the prospective group, including hours of hospitalization, number of methotrexate levels checked, weight gained during admission, and adherence to the guideline. CONCLUSION Among patients who received high-dose methotrexate, implementation of a guideline using a methotrexate threshold of <0.1 µmol was able to significantly decrease the time to discontinuation of supportive care and subsequently may lead to early hospital discharge given that we did not show a statistical significance.
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Affiliation(s)
- Thomas J Nowak
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aaron H Lorge
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa E Rein
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
| | - Angela M Canadeo
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joel P Frank
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa C Samanas
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Ehab L Atallah
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
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Concomitant Administration of High-dose Methotrexate and Low-dose Aspirin Without Any Delay in Methotrexate Clearance in a Patient With Osteosarcoma: A Case Report and Review of the Literature. J Pediatr Hematol Oncol 2018; 40:e392-e393. [PMID: 28902079 DOI: 10.1097/mph.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Methotrexate (MTX) is a commonly used agent in the treatment of oncology patients whose clearance depends on renal health maintaining glomerular filtration and tubular secretion. Thus concomitant use of other drugs that utilize the same mechanism of clearance are generally avoided as this may contribute to increased MTX-associated toxicity. OBSERVATION Herein, we describe the use of low-dose aspirin with high-dose MTX in a patient with osteosarcoma. CONCLUSION Concomitant aspirin use did not affect the clearance of high-dose MTX and the patient did not experience any MTX-related toxicity including mucositis or renal impairment.
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Evaluation of the Novel Methotrexate Architect Chemiluminescent Immunoassay: Clinical Impact on Pharmacokinetic Monitoring. Ther Drug Monit 2018; 39:492-498. [PMID: 28682926 DOI: 10.1097/ftd.0000000000000434] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fluorescence polarization immunoassay (FPIA) has probably been the most widely used technique for the determination of methotrexate (MTX) concentrations in clinical laboratories. After its replacement by a novel architect chemiluminescent microparticle immunoassay (CMIA), it is essential to verify that there are no differences between the methods that can induce an error in leucovorin rescue with dire consequences for the patient. The objective of our study was to compare plasma/serum MTX measurements between CMIA and FPIA (reference method in this study) in the work conditions of a clinical pharmacokinetics unit to determine whether any difference would affect clinical decisions on the management of this drug. METHODS FPIA on TDx/FLx and CMIA on Architect ci8200 were simultaneously used to evaluate 127 clinical samples. Within-run (20 repetitions on same day) and between-run (20 repetitions on different days) imprecision was evaluated using 6 control samples provided by the manufacturer and diluting 2 of them by 50% for 0.03 and 0.22 μmol/L, respectively. The Passing-Bablok regression method, Bland-Altman plot, and concordance correlation coefficient (CCC) were used in the statistical analysis. RESULTS Within-run imprecision was <5% (3.6%-4.39%) and between-run imprecision <11% (2.42%-10.65%). Between-assay correlation for the studied concentration range (0.05-250 μmol/L) was CMIA = -0.026 + 1.033 FPIA (n = 127), r = 0.9963, and CCC = 0.9946. For samples <1.5 μmol/L (nondiluted) included in the assay calibration curve, the correlation was CMIA = -0.009 + 0.955 FPIA (n = 54), r = 0.9819, and CCC = 0.9807. No significant difference was observed between the measurements by the 2 assays, given that the 95% confidence interval of the ordinate at the origin included "0" (-0.020 to 0.0007), and the 95% confidence interval of the slope included 1 (0.923-1.020). The interchangeability of these assays was confirmed by Bland-Altman plot results, which showed a mean difference insignificant at concentrations <10 μmol/L. CONCLUSIONS The correlation between methods was excellent, and Passing-Bablok regression analysis detected no virtually difference in their results. Utilization of the CMIA-Architect assay to measure MTX concentrations would therefore not affect clinical decisions on MTX management, supporting its employment in routine MTX monitoring.
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Wang W, Leu J, Watson R, Xu Z, Zhou H. Investigation of the Mechanism of Therapeutic Protein-Drug Interaction Between Methotrexate and Golimumab, an Anti-TNFα Monoclonal Antibody. AAPS JOURNAL 2018; 20:63. [PMID: 29667047 DOI: 10.1208/s12248-018-0219-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/12/2018] [Indexed: 12/31/2022]
Abstract
A prominent example of human therapeutic protein-drug interaction (TP-DI) is between methotrexate (MTX) and anti-TNFα mAbs. One plausible mechanism for this TP-DI is through the pharmacodynamic effect of MTX on immunogenicity. However, there is no definitive evidence to substantiate this mechanism, and other competing hypotheses, such as MTX suppressing FcγRI expression thereby affecting mAb PK, have also been proposed. In order to understand this mechanism, a cynomolgus monkey study was conducted using golimumab as a model compound. Golimumab elicited high incidences of immunogenicity in healthy cynomolgus monkeys. Concomitant dosing of MTX delayed the onset and reduced the magnitude of anti-drug antibody (ADA) formation. The impact of MTX on golimumab PK correlated with the ADA status. Prior to ADA formation, MTX has no discernable effect on golimumab PK. Additionally, no alteration in FcγRI expression was observed following MTX treatment. The impact of MTX on golimumab immunogenicity and PK has been observed in patients with rheumatoid arthritis, psoriatic arthritis (PsA), and ankylosing spondylitis. In a representative phase 3 study of golimumab in patients with PsA, patients not receiving concomitant MTX was reported to have ~ 30% lower steady-state trough golimumab levels compared to those who received MTX. However, further analysis showed that PsA patients who were negative for ADA in both treatment groups had comparable trough levels of golimumab. Taken together, our results suggest that the mechanism of TP-DI between MTX and golimumab can mostly be attributed to the pharmacodynamic effect of MTX, i.e., the lowering of immunogenicity and immunogenicity-mediated clearance of mAbs.
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Affiliation(s)
- Weirong Wang
- Biologics Development Sciences, Janssen R&D, LLC, Spring House, Pennsylvania, 19477, USA
| | - Jocelyn Leu
- Global Clinical Pharmacology, Janssen R&D, LLC, Spring House, Pennsylvania, 19477, USA
| | - Rebecca Watson
- Biologics Development Sciences, Janssen R&D, LLC, Spring House, Pennsylvania, 19477, USA
| | - Zhenhua Xu
- Global Clinical Pharmacology, Janssen R&D, LLC, Spring House, Pennsylvania, 19477, USA
| | - Honghui Zhou
- Global Clinical Pharmacology, Janssen R&D, LLC, Spring House, Pennsylvania, 19477, USA.
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Paul B, Ibarra GSR, Hubbard N, Einhaus T, Astrakhan A, Rawlings DJ, Kiem HP, Peterson CW. Efficient Enrichment of Gene-Modified Primary T Cells via CCR5-Targeted Integration of Mutant Dihydrofolate Reductase. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2018; 9:347-357. [PMID: 30038938 PMCID: PMC6054698 DOI: 10.1016/j.omtm.2018.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/01/2018] [Indexed: 12/19/2022]
Abstract
Targeted gene therapy strategies utilizing homology-driven repair (HDR) allow for greater control over transgene integration site, copy number, and expression-significant advantages over traditional vector-mediated gene therapy with random genome integration. However, the relatively low efficiency of HDR-based strategies limits their clinical application. Here, we used HDR to knock in a mutant dihydrofolate reductase (mDHFR) selection gene at the gene-edited CCR5 locus in primary human CD4+ T cells and selected for mDHFR-modified cells in the presence of methotrexate (MTX). Cells were transfected with CCR5-megaTAL nuclease mRNA and transduced with adeno-associated virus containing an mDHFR donor template flanked by CCR5 homology arms, leading to up to 40% targeted gene insertion. Clinically relevant concentrations of MTX led to a greater than 5-fold enrichment for mDHFR-modified cells, which maintained a diverse TCR repertoire over the course of expansion and drug selection. Our results demonstrate that mDHFR/MTX-based selection can be used to enrich for gene-modified T cells ex vivo, paving the way for analogous approaches to increase the percentage of HIV-resistant, autologous CD4+ T cells infused into HIV+ patients, and/or for in vivo selection of gene-edited T cells for the treatment of cancer.
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Affiliation(s)
- Biswajit Paul
- Stem Cell and Gene Therapy Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Guillermo S Romano Ibarra
- Center for Immunity and Immunotherapies and Program for Cell and Gene Therapy, Seattle Children's Research Institute, Seattle, WA, USA
| | - Nicholas Hubbard
- Center for Immunity and Immunotherapies and Program for Cell and Gene Therapy, Seattle Children's Research Institute, Seattle, WA, USA
| | - Teresa Einhaus
- Stem Cell and Gene Therapy Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - David J Rawlings
- Center for Immunity and Immunotherapies and Program for Cell and Gene Therapy, Seattle Children's Research Institute, Seattle, WA, USA.,Department of Pediatrics, University of Washington, Seattle, WA, USA.,Department of Immunology, University of Washington, Seattle, WA, USA
| | - Hans-Peter Kiem
- Stem Cell and Gene Therapy Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Pathology, University of Washington, Seattle, WA, USA
| | - Christopher W Peterson
- Stem Cell and Gene Therapy Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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Umerez M, Garcia-Obregon S, Martin-Guerrero I, Astigarraga I, Gutierrez-Camino A, Garcia-Orad A. Role of miRNAs in treatment response and toxicity of childhood acute lymphoblastic leukemia. Pharmacogenomics 2018; 19:361-373. [PMID: 29469670 DOI: 10.2217/pgs-2017-0164] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Childhood acute lymphoblastic leukemia survival rates have increased remarkably during last decades due, in part, to intensive treatment protocols. However, therapy resistance and toxicity are still two important barriers to survival. In this context, pharmacoepigenetics arises as a tool to identify new predictive markers, required to guide clinicians on risk stratification and dose individualization. The present study reviews current evidence about miRNA implication on childhood acute lymphoblastic leukemia therapy resistance and toxicity. A total of 12 studies analyzing differential miRNA expression in relation to drug resistance and six studies exploring the association between miRNAs-related SNPs and drug-induced toxicities were identified. We pointed out to miR-125b together with miR-99a and/or miR-100 overexpression as markers of vincristine resistance and rs2114358 in mir-1206 as mucositis marker as the most promising results.
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Affiliation(s)
- Maitane Umerez
- Department of Genetics, Physic Anthropology & Animal Physiology, University of the Basque Country, UPV/EHU, Leioa, Spain
| | | | - Idoia Martin-Guerrero
- Department of Genetics, Physic Anthropology & Animal Physiology, University of the Basque Country, UPV/EHU, Leioa, Spain
| | - Itziar Astigarraga
- BioCruces Health Research Institute Pediatric Oncology Group, Barakaldo, Spain.,Department of Pediatrics, University Hospital Cruces, Barakaldo, Spain.,Pediatric Department, University of the BasqueCountry, UPV/EHU, Leioa, Spain
| | - Angela Gutierrez-Camino
- Department of Genetics, Physic Anthropology & Animal Physiology, University of the Basque Country, UPV/EHU, Leioa, Spain
| | - Africa Garcia-Orad
- Department of Genetics, Physic Anthropology & Animal Physiology, University of the Basque Country, UPV/EHU, Leioa, Spain.,BioCruces Health Research Institute Pediatric Oncology Group, Barakaldo, Spain
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Chen M, Luo W, Zhang Z, Wang R, Zhu Y, Yang H, Chen X. Synthesis of Multi-Au-Nanoparticle-Embedded Mesoporous Silica Microspheres as Self-Filtering and Reusable Substrates for SERS Detection. ACS APPLIED MATERIALS & INTERFACES 2017; 9:42156-42166. [PMID: 29140677 DOI: 10.1021/acsami.7b16618] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Surface-enhanced Raman-scattering-based (SERS-based) biosensing in biological fluids is constrained by nonspecific macromolecule adsorptions and disposable property of the SERS substrate. Here, novel multi-Au-nanoparticle-embedded mesoporous silica microspheres (AuNPs/mSiO2) were prepared using a one-pot method, which served as reliable substrates for SERS enhancement associated with salient features of self-filtering ability and reusability. The fabrication and physical characterization of AuNPs/mSiO2 microspheres were discussed, and SERS activity of this novel substrate was investigated by using 4-mercaptobenzoic acid (4-MBA) as Raman probe. The responses of our substrates to Raman intensities exhibited a SERS enhancement factor of 2.01 × 107 and high reproducibility (relative standard deviation of 6.13%). Proof-of-concept experiments were designed to evaluate the self-filtering ability of the substrates in bovine serum albumin (BSA) and human serum solution, separately. The results clearly demonstrate that mesoporous SiO2 can serve as a molecular sieve via size exclusion and avoid Raman signal interference of biomacromolecules in biological fluids. Subsequently, feasibility of practical application of AuNPs/mSiO2 microspheres was assessed by quantitative detection of methotrexate (MTA) in serum. The method exhibited good linearity between 1 and 110 nM with the correlation coefficients of 0.996, which proved that the obtained AuNPs/mSiO2 microspheres were good SERS substrates for determination of small biomolecules directly in biological fluids without need of manipulating samples. In addition, the substrate maintained its SERS response during multiple cycles, which was evaluated by recording Raman signals for 4-MBA before and after thermal annealing, thereby demonstrating the high thermostability and satisfactory reusability. These results offered the AuNPs/mSiO2 microspheres attractive advantages in their SERS biosensing.
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Affiliation(s)
- Miao Chen
- College of Chemistry and Chemical Engineering, Central South University , Changsha, Hunan 410083, China
| | - Wen Luo
- College of Chemistry and Chemical Engineering, Central South University , Changsha, Hunan 410083, China
| | - Zhimin Zhang
- College of Chemistry and Chemical Engineering, Central South University , Changsha, Hunan 410083, China
| | - Ranhao Wang
- College of Chemistry and Chemical Engineering, Central South University , Changsha, Hunan 410083, China
| | - Yuqiu Zhu
- College of Chemistry and Chemical Engineering, Central South University , Changsha, Hunan 410083, China
| | - Hua Yang
- College of Chemistry and Chemical Engineering, Central South University , Changsha, Hunan 410083, China
| | - Xiaoqing Chen
- College of Chemistry and Chemical Engineering, Central South University , Changsha, Hunan 410083, China
- Hunan Provincial Key Laboratory of Efficient and Clean Utilization of Manganese Resources, Central South University , Changsha, Hunan 410083, China
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Oxyphenbutazone promotes cytotoxicity in rats and Hep3B cellsvia suppression of PGE2 and deactivation of Wnt/β-catenin signaling pathway. Mol Cell Biochem 2017; 444:187-196. [DOI: 10.1007/s11010-017-3243-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 11/27/2017] [Indexed: 12/23/2022]
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Ramsey LB, Balis FM, O'Brien MM, Schmiegelow K, Pauley JL, Bleyer A, Widemann BC, Askenazi D, Bergeron S, Shirali A, Schwartz S, Vinks AA, Heldrup J. Consensus Guideline for Use of Glucarpidase in Patients with High-Dose Methotrexate Induced Acute Kidney Injury and Delayed Methotrexate Clearance. Oncologist 2017; 23:52-61. [PMID: 29079637 PMCID: PMC5759822 DOI: 10.1634/theoncologist.2017-0243] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 09/13/2017] [Indexed: 11/17/2022] Open
Abstract
An expert panel was convened to provide specific, expert consensus guidelines for the use of glucarpidase in patients who develop high‐dose methotrexate (HDMTX)‐induced nephrotoxicity and delayed methotrexate excretion. This guideline provides recommendations to identify the population of patients who would benefit from glucarpidase rescue by more precisely defining the absolute methotrexate concentrations associated with risk for severe or life‐threatening toxicity at several time points after the start of a HDMTX infusion. Acute kidney injury due to high‐dose methotrexate (HDMTX) is a serious, life‐threatening toxicity that can occur in pediatric and adult patients. Glucarpidase is a treatment approved by the Food and Drug Administration for high methotrexate concentrations in the context of kidney dysfunction, but the guidelines for when to use it are unclear. An expert panel was convened to provide specific, expert consensus guidelines for the use of glucarpidase in patients who develop HDMTX‐induced nephrotoxicity and delayed methotrexate excretion. The guideline provides recommendations to identify the population of patients who would benefit from glucarpidase rescue by more precisely defining the absolute methotrexate concentrations associated with risk for severe or life‐threatening toxicity at several time points after the start of an HDMTX infusion. For an HDMTX infusion ≤24 hours, if the 36‐hour concentration is above 30 µM, 42‐hour concentration is above 10 µM, or 48‐hour concentration is above 5 µM and the serum creatinine is significantly elevated relative to the baseline measurement (indicative of HDMTX‐induced acute kidney injury), glucarpidase may be indicated. After a 36‐ to 42‐hour HDMTX infusion, glucarpidase may be indicated when the 48‐hour methotrexate concentration is above 5 µM. Administration of glucarpidase should optimally occur within 48–60 hours from the start of the HDMTX infusion, because life‐threatening toxicities may not be preventable beyond this time point. Implications for Practice. Glucarpidase is a rarely used medication that is less effective when given after more than 60 hours of exposure to high‐dose methotrexate, so predicting early which patients will need it is imperative. There are no currently available consensus guidelines for the use of this medication. The indication on the label does not give specific methotrexate concentrations above which it should be used. An international group of experts was convened to develop a consensus guideline that was specific and evidence‐based to identify the population of patients who would benefit from glucarpidase.
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Affiliation(s)
- Laura B Ramsey
- Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Frank M Balis
- Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Maureen M O'Brien
- Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, and Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jennifer L Pauley
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Archie Bleyer
- Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Brigitte C Widemann
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - David Askenazi
- Pediatric and Infant Center for Acute Nephrology, Professor of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sharon Bergeron
- Hyundai Cancer Institute, Children's Hospital of Orange County, Orange, California, USA
| | - Anushree Shirali
- Assistant Professor of Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Stefan Schwartz
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Alexander A Vinks
- Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jesper Heldrup
- Childhood Cancer and Research Unit, University Children's Hospital, Lund, Sweden
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Lohitnavy M, Lohitnavy O, Yang RSH. A physiologically-based pharmacokinetic model of methotrexate incorporating hepatic excretion via multidrug-resistance-associated protein 2 (Mrp2) in mice, rats, dogs, and humans. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2017:2728-2731. [PMID: 29060462 DOI: 10.1109/embc.2017.8037421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
An updated physiologically-based pharmacokinetic (PBPK) model of methotrexate (MTX) was built based on an earlier model developed by Bischoff et al. (1971). MTX has been known to be a substrate of multidrug-resistance-associated protein 2 (Mrp2). A three-dimensional quantitative structure-activity relationship model (3D-QSAR) of Mrp2 was developed by Hirono et al. (2005). In our updated PBPK model of MTX, using the computational chemistry-derived binding affinity (Km), a Mrp2-mediated biliary excretion process was incorporated as the MTX excretory pathway. Our model simulation results are consistent with numerous datasets obtained from mice, rats, dogs, and humans, at a variety of dose levels. Comparisons were made between our updated PBPK model and the earlier one from Bischoff et al. using a PBPK Index approach. Our new PBPK model was further verified against additional pharmacokinetic datasets from rats under special experimental conditions (cannulated bile duct) and Eisai hyperbirilubinemic rats.
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Ambulatory High-dose Methotrexate Administration in Pediatric Osteosarcoma Patients at a Single Institution in Argentina. J Pediatr Hematol Oncol 2017; 39:e349-e352. [PMID: 28937522 DOI: 10.1097/mph.0000000000000922] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the feasibility and safety of ambulatory high-dose methotrexate (HDMTX) administration with oral hydration, alkalinization, and leucovorin rescue. HDMTX (12 g/m) was given intravenously over 4 hours after urine alkalinization. Families and patients were instructed to continue ambulatory oral hydration and alkalinization to monitor urine pH and to adjust bicarbonate according to our institution's treatment algorithm. Clinical status and MTX levels were controlled every 24 hours, and oral leucovorin dose was adjusted accordingly. RESULTS From April 2007 to December 2010, 150 of 447 courses of HDMTX (31.4%) were given on an outpatient basis, and 91.2% were successfully completed. The main causes of failure were poor oral tolerance (n=6) and fever (n=4). Most patients (81%) had MTX levels of <10 μmol/L 24 hours post-HDMTX; only in 1 course the levels were >50 μmol/L (50.96 μmol/L). Neutropenia grade III/IV was observed in 18.3% of the courses, grade III/IV leukopenia in 2.7%, and grade III/IV thrombocytopenia and anemia in 4.7%. Around 39% were associated with grade III/IV hepatic toxicity (asymptomatic hypertransaminasemia), grade III-IV gastrointestinal toxicity (vomiting and diarrhea) (5%), grade III-IV mucositis (4%), and none of the patients developed renal toxicity. CONCLUSIONS Ambulatory HDMTX administration is feasible and safe in a population with poor resources in a developing country.
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Chen M, Luo W, Zhang Z, Zhu F, Liao S, Yang H, Chen X. Sensitive surface enhanced Raman spectroscopy (SERS) detection of methotrexate by core-shell-satellite magnetic microspheres. Talanta 2017; 171:152-158. [DOI: 10.1016/j.talanta.2017.04.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 04/24/2017] [Accepted: 04/30/2017] [Indexed: 10/19/2022]
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Drost SA, Wentzell JR, Giguère P, McLurg DL, Sabloff M, Kanji S, Nguyen TT. Outcomes Associated with Reducing the Urine Alkalinization Threshold in Patients Receiving High-Dose Methotrexate. Pharmacotherapy 2017; 37:684-691. [PMID: 28394433 DOI: 10.1002/phar.1935] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
STUDY OBJECTIVES Urine alkalinization increases methotrexate (MTX) solubility and reduces the risk of nephrotoxicity. The objectives of this study were to determine whether a reduction in the urine pH threshold from 8 to 7 in patients receiving high-dose methotrexate (HDMTX) results in a shorter length of hospital stay, delayed MTX clearance, or higher rates of nephrotoxicity; and to determine whether specific factors were associated with prolonged MTX clearance. DESIGN Retrospective cohort study. SETTING Hematology service of a large university-affiliated teaching hospital in Ottawa, Canada. PATIENTS Sixty-five adults with 150 HDMTX exposures who had elective admissions for HDMTX between September 1, 2014, and December 18, 2015, were included. Thirty-four patients (with 79 HDMTX exposures) had their urine alkalinized to a pH of 8 or higher, and 31 patients (with 71 HDMTX exposures) had their urine alkalinized to a pH of 7 or higher, after an institutional change in the urine pH threshold from 8 to 7 was implemented on May 1, 2015. MEASUREMENTS AND MAIN RESULTS Data related to patient demographics, urine alkalinization, MTX serum concentration monitoring, hospital length of stay, and renal function were collected retrospectively from patients' electronic health records. Lowering the urine pH threshold from 8 to 7 did not significantly affect hospital length of stay (absolute difference 3.5 hrs, 95% confidence interval -4.0 to 10.9) or clearance of MTX (elimination rate constant 0.058 in the pH of 7 or higher group vs 0.064 in the pH of 8 or higher group, p=0.233). Nephrotoxicity rates were similar between groups (15.5% in the pH of 7 or higher group vs 10.1% in the pH of 8 or higher group, p=0.34). Higher MTX dose and interacting medications (e.g., proton pump inhibitors and sulfonamide antibiotics) were significantly associated with delayed MTX elimination. CONCLUSION No significant differences in HDMTX-associated hospital length of stay, MTX clearance, or rates of nephrotoxicity were noted between patients in the urine pH of 7 or higher and 8 or higher groups. Interacting medications and higher MTX dose were associated with delayed MTX elimination, suggesting that a closer review of interacting medications before HDMTX administration may be warranted.
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Affiliation(s)
- Sarah A Drost
- Pharmacy Department, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jason R Wentzell
- Pharmacy Department, The Ottawa Hospital, Ottawa, Ontario, Canada.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Pierre Giguère
- Pharmacy Department, The Ottawa Hospital, Ottawa, Ontario, Canada.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Darcy L McLurg
- Pharmacy Department, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Mitchell Sabloff
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Salmaan Kanji
- Pharmacy Department, The Ottawa Hospital, Ottawa, Ontario, Canada.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Tiffany T Nguyen
- Pharmacy Department, The Ottawa Hospital, Ottawa, Ontario, Canada
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