Affiliations of authors: F. M. Balis, Pediatric Oncology Branch, Division of Clinical Sciences, National Cancer Institute, Bethesda, MD; P. C. Adamson, Division of Clinical Pharmacology and Therapeutics, Children's Hospital of Philadelphia, PA.
Correspondence to: Frank M. Balis, M.D., National Institutes of Health, Bldg. 10, Rm. 13N240, Bethesda, MD 20892-1928.
The traditional approach to dosing anticancer drugs is to administer a standard starting dose, which is normalized to body surface area, and then to adjust or individualize subsequent doses based on the severity of ensuing drug toxicity. Dosing according to body surface area is based on the assumption that the volume of distribution and drug elimination mechanisms are proportional to the body surface area. However, pharmacokinetic studies of anticancer drugs typically reveal substantial interpatient variability in plasma drug concentrations when the dose is based on body surface area (1). The potential consequences of this variability in systemic drug exposure are life-threatening toxic effects in patients who are exposed to overly toxic drug concentrations and tumor progression in patients who achieve subtherapeutic drug concentrations. The identification of specific factors that account for variability in drug disposition among patients can lead to more rational dosing methods such as adaptively dosing carboplatin based on glomerular filtration rate.
For the purine analogue mercaptopurine, which is used to maintain remission in childhood acute lymphoblastic leukemia (ALL), the standard starting dose is 75 mg/m2 day orally, and subsequent dose adjustments are based primarily on the degree of suppression of the neutrophil count. Plasma mercaptopurine concentrations after oral administration of the drug are highly variable (2-4). The area under the plasma concentration-time curve (AUC), which is a measure of systemic drug exposure, can vary by as much as 70-fold in a homogeneous population of children, who are dosed in a uniform manner (4). Mercaptopurine pharmacokinetic variability has prompted studies (4-6) to investigate the relationship between pharmacokinetic parameters, such as AUC, and disease outcome. These studies have failed to define a role for therapeutic drug monitoring or to identify more rational a priori adaptive dosing methods based on patient characteristics for mercaptopurine, in part because of the substantial intrapatient variability in mercaptopurine pharmacokinetics (4).
Mercaptopurine is a prodrug that must be converted intracellularly to its thioguanine
nucleotide form to exert a cytotoxic effect (7). The competing pathways
for mercaptopurine activation and catabolism are shown in Fig. 1.
Oxidation to thiouric acid by xanthine oxidase is the primary catabolic pathway. Extensive
presystemic (first-pass) metabolism of mercaptopurine by xanthine oxidase also limits the
bioavailability of oral mercaptopurine (2). The first step in the intracellular
activation of mercaptopurine is catalyzed by hypoxanthine-guanine phosphoribosyltransferase,
which yields thioinosine monophosphate (TIMP). TIMP is subsequently converted to thioguanine
triphosphate, which is incorporated into DNA. Although methylation of the thiol group on
mercaptopurine and TIMP by thiopurine methyltransferase (TPMT) yields metabolites that can
inhibit steps in the purine salvage pathway, thiol methylation is the initial step in primarily
catabolic pathways for mercaptopurine and TIMP. Methylation competes with the activation
pathway and modulates the size of the active thioguanine nucleotide intracellular pools in the
target cells.
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Methylation of drugs is a common metabolic pathway, as evidenced by the fact that more than 100 methyltransferase enzymes have been identified (11). TPMT, which catalyzes the S-methylation of aromatic and heterocyclic compounds, utilizes S-adenosylmethionine as a methyl donor. Measurement of TPMT activity in erythrocytes led to the discovery that TPMT is genetically polymorphic. This was subsequently confirmed through genotyping (12,13). At least eight variant alleles of TPMT with low enzyme activity have been cloned and sequenced (11), and the gene frequency of the variant alleles is 6%. The functional significance of this TPMT polymorphism was observed in the one in 300 patients who are homozygous for the low enzyme activity variant alleles. These patients have markedly elevated erythrocyte thioguanine nucleotide levels and experience severe and often life-threatening toxic effects when treated with standard doses of thiopurines (14), but they will tolerate these agents at drastically reduced dose levels. On the basis of this observation and studies that demonstrated that TPMT activity in erythrocytes is predictive of enzyme activity in other tissues, erythrocyte TPMT activity is measured before the initiation of thiopurine therapy at many centers to identify the 0.3% of patients who are at high risk for excessive thiopurine-induced toxicity (11).
In this issue of the Journal, Relling et al. (15) provide evidence that intermediate TPMT activity in approximately 11% of the patients who are heterozygotes at the TPMT locus also appears to have clinical significance in a homogeneous population of children with ALL. The genotype of TPMT was inferred from erythrocyte TPMT levels, and patients were divided into wild-type, heterozygous, and homozygous (TPMT-deficient) groups. In a subset of patients who were genotyped, there was complete concordance between phenotype and genotype. Erythrocyte thioguanine nucleotide levels were highest in the TPMT-deficient patients, intermediate in the heterozygous group, and lowest in the wild-type genotype group. More important, the optimal dose of mercaptopurine, which was determined in the standard empirical fashion on the basis of the neutrophil count and total white blood cell count, was also related to TPMT genotype. The tolerable mercaptopurine dose in the homozygous-deficient patients was 14% of the dose tolerated in patients with the homozygous wild-type genotype, confirming previous reports (16,17), and the tolerable dose in the heterozygous group (mean, 64 mg/m2 day) was 85% of the dose in the wild-type group (mean, 75 mg/m2 per day).
The authors did not provide specific mercaptopurine a priori adaptive dosing guidelines based on TPMT genotype, presumably because erythrocyte TPMT levels were measured during and after mercaptopurine therapy in this study rather than before the initiation of therapy. However, pharmacogenetically guided dosing of mercaptopurine based on TPMT genotype appears to offer a more rational dosing approach than the traditional empirical method or pharmacokinetically guided dosing based on plasma mercaptopurine concentration or erythrocyte thioguanine nucleotide levels. This study also illustrates the potential utility of pharmacogenetic studies in prospectively defining subsets of patients who may be less tolerant of anticancer drugs based on their capacity to metabolize (detoxify) the drugs. Considering the number of xenobiotic-metabolizing enzymes with polymorphisms (18), pharmacogenetically guided dosing may eventually be applicable to many other anticancer drugs. Once the genetic alterations that are responsible for the polymorphism are identified, polymerase chain reaction-based screening tests can be developed to prospectively provide a profile of drug-metabolizing capacity for each patient.
Categorizing patients according to genotype for relatively uncommon polymorphisms will only identify a small subset of patients who would benefit from pharmacogenetically guided dosing, whereas phenotyping patients by estimating enzyme activity may also allow for individualization of drug doses within the population of patients with homozygous wild-type genotype. For some drug-metabolizing enzymes, there is a wide range of enzyme activity within the wild-type group, as is the case with TPMT, and many drug-metabolizing enzyme systems are inducible. Assessing the relationship between TPMT activity and mercaptopurine dose in a manner similar to the analysis shown in Fig. 4 by Relling et al. (15) for thioguanine nucleotide levels may identify a subpopulation within the TPMT wild-type group who could also benefit from adaptive dosing based on erythrocyte TPMT levels.
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