Extensive Metabolism and Hepatic Accumulation of Gemcitabine After Multiple Oral and Intravenous Administration in Mice

ABSTRACT: In a clinical study with oral gemcitabine (2,2-difluorodeoxycytidine, dFdC), we found that gemcitabine was hepatotoxic and extensively metabolized to 2,2-difluorodeoxyuridine (dFdU) after continuous oral dosing. The main metabolite dFdU had a long terminal half-life after oral administration. Our hypothesis was that dFdU and/or phosphorylated metabolites of gemcitabine accumulated in the liver after multiple oral dosing. In this study, mice were treated with oral or i.v. dFdC at a single dose (1qd؋1d) or at multiple doses once daily for 7 days (1qd؋7d) or seven times daily (7qd؋1d). Blood, liver, kidneys, and lungs were collected at several time points. Urine samples were collected after i.v. dFdC, and peripheral blood mononuclear cells were collected 7qd؋1d dosing of dFdC. The nucleosides dFdC and dFdU as well as the nucleotides gemcitabine monophosphate (dFdC-MP), diphosphate, and triphosphate (dFdC-TP) and dFdU monophosphate, diphosphate (dFdU-DP), and triphosphate (dFdU-TP) were simultaneously quantified by high-performance liquid chromatography with ultraviolet and radioisotope detection. We demonstrate that phosphorylated metabolites of both dFdC and dFdU are formed in mice, primarily consisting of dFdC-MP, dFdC-TP, and dFdU-TP. Multiple dosing of dFdC leads to substantial hepatic and renal accumulation of dFdC-TP and dFdU-TP, which have a more pronounced liver accumulation after oral than after i.v. dosing. The presence of dFdC-MP, dFdC-TP, and dFdU-TP in plasma and urine suggests efflux of these potentially toxic metabolites. Our results show that dFdU, dFdC-TP, and dFdU-TP accumulate in the liver after multiple dosing of dFdC in mice and might be associated with hepatotoxicity of oral dFdC in patients. Gemcitabine (2Ј,2Ј-difluorodeoxycytidine, dFdC), a pyrimidine nucleoside anticancer drug, is used in the treatment of patients with a variety of solid tumors Alternatively, dFdC is deaminated to 2Ј,2Ј-difluorodeoxyuridine (dFdU) by cytidine deaminase (CDA), which is highly expressed in human liver and mice kidney In a clinical study, dFdC was orally administered in continuous dosing regimens at low dose levels in patients with advanced solid tumors . The exposure to dFdC was low because of extensive first-pass metabolism to dFdU. Additionally, we found that the triphosphate form of dFdU (dFdU-TP) was formed at high exposure levels in peripheral blood mononuclear cells (PBMCs). One patient treated with 8 mg of oral dFdC once daily for 14 days of a 21-day cycle developed lethal hepatic toxicity during the second cycle. Pathological examination revealed severe drug-induced liver necrosis. Pharmacokinetic analysis demonstrated that dFdU has a long terminal half-life (t 1/2 ) (ϳ89 h) and appeared to accumulate in the liver of patients. Based on these findings, we hypothesized that continuous daily oral dosing of dFdC results in liver accumulation of dFdU and/or phosphorylated metabolites in patients, possibly associated with the hepatotoxicity of dFdC. We recently found that dFdU is Article, publication date, and citation information can be found at http://dmd.aspetjournals.org. doi:10.1124/dmd.108.021048. ABBREVIATIONS: dFdC, 2Ј,2Ј-difluorodeoxycytidine (gemcitabine); dCK, deoxycytidine kinase; dFdC-MP, gemcitabine monophosphate; dFdC-TP, gemcitabine triphosphate; dFdC-DP, gemcitabine diphosphate; dFdU, 2Ј,2Ј-difluorodeoxyuridine; CDA, cytidine deaminase; dFdU-TP, dFdU triphosphate; PBMC, peripheral blood mononuclear cell; hCNT1, human concentrative nucleoside transporter type 1; PK, pharmacokinetics; 1qdϫ1d, single dose on day 1; 1qdϫ7d, once daily dosing for 7 days; 7qdϫ1d, seven times daily dosing for 1 day; dFdU-MP, dFdU monophosphate; dFdU-DP, dFdU diphosphate; THU, tetrahydrouridine; AP, alkaline phosphatase; HPLC, high-performance liquid chromatography; AUC, area under the curve

Clinical and Pharmacologic Study of the Novel Prodrug Delimotecan (MEN 4901/T-0128) in Patients with Solid Tumors

Purpose: To investigate i.v. administration of delimotecan (MEN 4901/T-0128), a carboxymethyldextran polymer prodrug of the active camptothecin derivative T-2513, and to assess the maximum tolerated dose, safety profile, clinical pharmacology, and antitumor activity of delimotecan and metabolites. Experimental Design: Patients with solid tumors refractory to standard therapy received i.v. delimotecan as 3-hour infusion once every 6 weeks. The starting dose was 150 mg/m(2), followed by an accelerated dose escalation with at least one patient per dose level. The pharmacokinetics of delimotecan, T-2513, and its metabolites, SN-38, SN-38G, T-1335, T-0055, and T-3921, were assessed in plasma and urine, and their pharmacodynamics were determined by measuring the effect of the treatment on hematologic and nonhematologic toxicity. Results: Twenty-two patients received 35 courses. Dose-limiting toxicities were observed at 5,400 mg/m(2) (n = 1), 3,600 mg/m(2) (n = 1), and 2,400 mg/m(2) (n = 2). The dose level of 1,800 mg/m(2) was determined as maximum tolerated dose. Two partial responses were observed in patients with anal cancer (1800 mg/m(2)) and head and neck cancer (2400 mg/m(2)). Delimotecan had a long terminal half-life of 109 h, and relatively high exposures to T-2513 and SN-38 were obtained. The percentage decrease in WBC and absolute neutrophil count significantly correlated with the dose of delimotecan. Conclusions: Based on its preliminary antitumor activity, safety profile, and pharmacokinetic profile, we recommend to evaluate delimotecan given as 3-hour infusion once every 6 weeks at a dose level of 1,800 mg/m(2) in a phase II study