Maarten J Deenen1, Didier Meulendijks1, Annemieke Cats1, Marjolein K Sechterberger1, Johan L Severens1, Henk Boot1, Paul H Smits1, Hilde Rosing1, Caroline M P W Mandigers1, Marcel Soesan1, Jos H Beijnen1, Jan H M Schellens2. 1. Maarten J. Deenen, Didier Meulendijks, Annemieke Cats, Marjolein K. Sechterberger, Henk Boot, Hilde Rosing, Jos H. Beijnen, and Jan H.M. Schellens, Netherlands Cancer Institute; Paul H. Smits and Marcel Soesan, Slotervaart Hospital, Amsterdam; Johan L. Severens, Erasmus University Medical Center, Rotterdam; Caroline M.P.W. Mandigers, Canisius Wilhelmina Hospital, Nijmegen; and Jos H. Beijnen and Jan H.M. Schellens, Utrecht University, Utrecht, the Netherlands. 2. Maarten J. Deenen, Didier Meulendijks, Annemieke Cats, Marjolein K. Sechterberger, Henk Boot, Hilde Rosing, Jos H. Beijnen, and Jan H.M. Schellens, Netherlands Cancer Institute; Paul H. Smits and Marcel Soesan, Slotervaart Hospital, Amsterdam; Johan L. Severens, Erasmus University Medical Center, Rotterdam; Caroline M.P.W. Mandigers, Canisius Wilhelmina Hospital, Nijmegen; and Jos H. Beijnen and Jan H.M. Schellens, Utrecht University, Utrecht, the Netherlands. j.schellens@nki.nl.
Abstract
PURPOSE: Fluoropyrimidines are frequently prescribed anticancer drugs. A polymorphism in the fluoropyrimidine metabolizing enzyme dihydropyrimidine dehydrogenase (DPD; ie, DPYD*2A) is strongly associated with fluoropyrimidine-induced severe and life-threatening toxicity. This study determined the feasibility, safety, and cost of DPYD*2A genotype-guided dosing. PATIENTS AND METHODS: Patients intended to be treated with fluoropyrimidine-based chemotherapy were prospectively genotyped for DPYD*2A before start of therapy. Variant allele carriers received an initial dose reduction of ≥ 50% followed by dose titration based on tolerance. Toxicity was the primary end point and was compared with historical controls (ie, DPYD*2A variant allele carriers receiving standard dose described in literature) and with DPYD*2A wild-type patients treated with the standard dose in this study. Secondary end points included a model-based cost analysis, as well as pharmacokinetic and DPD enzyme activity analyses. RESULTS: A total of 2,038 patients were prospectively screened for DPYD*2A, of whom 22 (1.1%) were heterozygous polymorphic. DPYD*2A variant allele carriers were treated with a median dose-intensity of 48% (range, 17% to 91%). The risk of grade ≥ 3 toxicity was thereby significantly reduced from 73% (95% CI, 58% to 85%) in historical controls (n = 48) to 28% (95% CI, 10% to 53%) by genotype-guided dosing (P < .001); drug-induced death was reduced from 10% to 0%. Adequate treatment of genotype-guided dosing was further demonstrated by a similar incidence of grade ≥ 3 toxicity compared with wild-type patients receiving the standard dose (23%; P = .64) and by similar systemic fluorouracil (active drug) exposure. Furthermore, average total treatment cost per patient was lower for screening (€2,772 [$3,767]) than for nonscreening (€2,817 [$3,828]), outweighing screening costs. CONCLUSION: DPYD*2A is strongly associated with fluoropyrimidine-induced severe and life-threatening toxicity. DPYD*2A genotype-guided dosing results in adequate systemic drug exposure and significantly improves safety of fluoropyrimidine therapy for the individual patient. On a population level, upfront genotyping seemed cost saving.
PURPOSE:Fluoropyrimidines are frequently prescribed anticancer drugs. A polymorphism in the fluoropyrimidine metabolizing enzyme dihydropyrimidine dehydrogenase (DPD; ie, DPYD*2A) is strongly associated with fluoropyrimidine-induced severe and life-threatening toxicity. This study determined the feasibility, safety, and cost of DPYD*2A genotype-guided dosing. PATIENTS AND METHODS: Patients intended to be treated with fluoropyrimidine-based chemotherapy were prospectively genotyped for DPYD*2A before start of therapy. Variant allele carriers received an initial dose reduction of ≥ 50% followed by dose titration based on tolerance. Toxicity was the primary end point and was compared with historical controls (ie, DPYD*2A variant allele carriers receiving standard dose described in literature) and with DPYD*2A wild-type patients treated with the standard dose in this study. Secondary end points included a model-based cost analysis, as well as pharmacokinetic and DPD enzyme activity analyses. RESULTS: A total of 2,038 patients were prospectively screened for DPYD*2A, of whom 22 (1.1%) were heterozygous polymorphic. DPYD*2A variant allele carriers were treated with a median dose-intensity of 48% (range, 17% to 91%). The risk of grade ≥ 3 toxicity was thereby significantly reduced from 73% (95% CI, 58% to 85%) in historical controls (n = 48) to 28% (95% CI, 10% to 53%) by genotype-guided dosing (P < .001); drug-induced death was reduced from 10% to 0%. Adequate treatment of genotype-guided dosing was further demonstrated by a similar incidence of grade ≥ 3 toxicity compared with wild-type patients receiving the standard dose (23%; P = .64) and by similar systemic fluorouracil (active drug) exposure. Furthermore, average total treatment cost per patient was lower for screening (€2,772 [$3,767]) than for nonscreening (€2,817 [$3,828]), outweighing screening costs. CONCLUSION: DPYD*2A is strongly associated with fluoropyrimidine-induced severe and life-threatening toxicity. DPYD*2A genotype-guided dosing results in adequate systemic drug exposure and significantly improves safety of fluoropyrimidine therapy for the individual patient. On a population level, upfront genotyping seemed cost saving.
Authors: Bart A W Jacobs; Nikol Snoeren; Morsal Samim; Hilde Rosing; Niels de Vries; Maarten J Deenen; Jos H Beijnen; Jan H M Schellens; Miriam Koopman; Richard van Hillegersberg Journal: Eur J Clin Pharmacol Date: 2018-02-11 Impact factor: 2.953
Authors: Jan H Beumer; Edward Chu; Carmen Allegra; Yusuke Tanigawara; Gerard Milano; Robert Diasio; Tae Won Kim; Ron H Mathijssen; Li Zhang; Dirk Arnold; Katsuki Muneoka; Narikazu Boku; Markus Joerger Journal: Clin Pharmacol Ther Date: 2018-09-11 Impact factor: 6.875
Authors: Ursula Amstutz; Linda M Henricks; Steven M Offer; Julia Barbarino; Jan H M Schellens; Jesse J Swen; Teri E Klein; Howard L McLeod; Kelly E Caudle; Robert B Diasio; Matthias Schwab Journal: Clin Pharmacol Ther Date: 2017-11-20 Impact factor: 6.875