Fluorouracil

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Fluorouracil
Fluorouracil2DACS.svg
Fluorouracil3DanZ.gif
Systematic (IUPAC) name
5-Fluoro-1H,3H-pyrimidine-2,4-dione
Clinical data
Pronunciation /ˌflʊrˈjʊrəˌsɪl/[1]
Trade names Adrucil, Carac, Efudex, Efudix
AHFS/Drugs.com Monograph
MedlinePlus a682708
License data
Pregnancy
category
  • AU: D

  • D (IV), X (topical) (US)
Routes of
administration
IV (infusion or bolus) and topical
Legal status
Legal status
Pharmacokinetic data
Bioavailability 28 to 100%
Protein binding 8 to 12%
Metabolism Intracellular and hepatic (CYP-mediated)
Biological half-life 16 minutes
Excretion Renal
Identifiers
CAS Number 51-21-8 YesY
ATC code L01BC02 (WHO)
PubChem CID 3385
IUPHAR/BPS 4789
DrugBank DB00544 YesY
ChemSpider 3268 YesY
UNII U3P01618RT YesY
KEGG D00584 YesY
ChEBI CHEBI:46345 YesY
ChEMBL CHEMBL185 YesY
Chemical data
Formula C4H3FN2O2
Molar mass 130.077 g/mol
Physical data
Melting point 282–283 °C (540–541 °F)
  (verify)

Fluorouracil (5-FU) (trade name Adrucil among others) is a medication which is used in the treatment of cancer.

It is a suicide inhibitor and works through irreversible inhibition of thymidylate synthase. It belongs to the family of drugs called the antimetabolites.[2] It is also a pyrimidine analog .

It is on the World Health Organization's List of Essential Medicines, the most important medications needed in a basic health system.[3]

Medical uses[edit]

Fluorouracil has been given systemically for anal, breast, colorectal, oesophageal, stomach, pancreatic and skin cancers (especially head and neck cancers).[4] It has also been given topically (on the skin) for actinic keratoses, skin cancers and Bowen's disease[4] and as eye drops for treatment of ocular surface squamous neoplasia.[5]

Contraindications[edit]

It is contraindicated in patients that are severely debilitated or in patients with bone marrow suppression due to either radiotherapy or chemotherapy.[6] It is likewise contraindicated in pregnant or breastfeeding women.[6] It should also be avoided in patients that do not have malignant illnesses.[6]

Adverse effects[edit]

Adverse effects by frequency include:[4][6][7][8][9][10][11][12][13]

During systemic use[edit]

Common (> 1% frequency):

  • Nausea
  • Vomiting
  • Diarrhea (see below for details)
  • Mucositis
  • Headache
  • Myelosuppression (see below for details)
  • Alopecia (hair loss)
  • Photosensitivity
  • Hand-foot syndrome
  • Maculopapular eruption
  • Itch
  • Cardiotoxicity (see below for details)
  • Persistent hiccups
  • Mood disorders (irritability, anxiety, depression)

Uncommon (0.1–1% frequency):

  • Oesophagitis
  • GI ulceration and bleeding
  • Proctitis
  • Nail disorders
  • Vein pigmentation
  • Confusion
  • Cerebellar syndrome
  • Encephalopathy
  • Visual changes
  • Photophobia
  • Lacrimation (the expulsion of tears without any emotional or physiologic reason)

Rare (< 0.1% frequency):

  • Anaphylaxis
  • Allergic reactions
  • Fever without signs of infection

Diarrhea is severe and may be dose-limiting and is exacerbated by co-treatment with calcium folinate.[4] Neutropenia tends to peak about 9–14 days after beginning treatment.[4] Thrombocytopenia tends to peak about 7–17 days after the beginning of treatment and tends to recover about 10 days after its peak.[4] Cardiotoxicity is a fairly common side effect, but usually this cardiotoxicity is just angina or symptoms associated with coronary artery spasm, but in about 0.55% of those receiving the drug will develop life-threatening cardiotoxicity.[medical citation needed] Life-threatening cardiotoxicity includes: arrhythmias, ventricular tachycardia and cardiac arrest, secondary to transmural ischaemia.[medical citation needed]

During topical use[edit]

[4][9]

Common (> 1% frequency):

  • Local pain
  • Itchiness
  • Burning
  • Stinging
  • Crusting
  • Weeping
  • Dermatitis
  • Photosensitivity

Uncommon (0.1–1% frequency):

  • hyper- or hypopigmentation
  • Scarring

Neurological damage[edit]

5-FU injection and topical even in small doses cause both acute central nervous system (CNS) damage and progressively worsening delayed degeneration of the CNS in mice. This latter effect is caused by 5-FU-induced damage to the oligodendrocytes that produce the insulating myelin sheaths. [14] [15]

The United States package insert warns that acute cerebellar syndrome has been observed following injection of fluorouracil and may persist after cessation of treatment. Symptoms include Ataxia, nystagmus, and dysmetria.[16]

Potential overdose[edit]

There is very little difference between the minimum effective dose and maximum tolerated dose of 5-FU, and the drug exhibits marked individual pharmacokinetic variability.[17][18][19] Therefore, an identical dose of 5-FU may result in a therapeutic response with acceptable toxicity in some patients and unacceptable and possibly life-threatening toxicity in others.[17] Both overdosing and underdosing are of concern with 5-FU, although several studies have shown that the majority of colorectal cancer patients treated with 5-FU are underdosed based on today's dosing standard, body surface area (BSA).[20][21][22][23] The limitations of BSA-based dosing prevent oncologists from being able to accurately titer the dosage of 5-FU for the majority of individual patients, which results in sub-optimal treatment efficacy or excessive toxicity.[20][21]

Numerous studies have found significant relationships between concentrations of 5-FU in blood plasma and both desirable or undesirable effects on patients.[24][25] Studies have also shown that dosing based on the concentration of 5-FU in plasma can greatly increase desirable outcomes while minimizing negative side effects of 5-FU therapy.[20][26] One such test that has been shown to successfully monitor 5-FU plasma levels and which "may contribute to improved efficacy and safety of commonly used 5-FU-based chemotherapies" is the My5-FU test.[22][27][28]

Interactions[edit]

Its use should be avoided in patients receiving drugs known to modulate dihydropyrimidine dehydrogenase (such as the antiviral drug sorivudine).[6] It may also increase the INR and prothrombin times in patients on warfarin.[6] Fluoruracil's efficacy is decreased when used alongside allopurinol which can be used to decrease fluoruracil induced stomatitis through use of allopurinol mouthwash.[29]

Pharmacology[edit]

Pharmacogenetics[edit]

The dihydropyrimidine dehydrogenase (DPD) enzyme is responsible for the detoxifying metabolism of fluoropyrimidines, a class of drugs that includes 5-fluorouracil, capecitabine, and tegafur.[30] Genetic variations within the DPD gene (DPYD) can lead to reduced or absent DPD activity, and individuals who are heterozygous or homozygous for these variations may have partial or complete DPD deficiency; an estimated 0.2% of individuals have complete DPD deficiency.[30][31] Those with partial or complete DPD deficiency have a significantly increased risk of severe or even fatal drug toxicities when treated with fluoropyrimidines; examples of toxicities include myelosuppression, neurotoxicity and hand-foot syndrome.[30][31]

Mechanism of action[edit]

5-FU acts in several ways, but principally as a thymidylate synthase (TS) inhibitor. Interrupting the action of this enzyme blocks synthesis of the pyrimidine thymidine, which is a nucleoside required for DNA replication. Thymidylate synthase methylates deoxyuridine monophosphate (dUMP) to form thymidine monophosphate (dTMP). Administration of 5-FU causes a scarcity in dTMP, so rapidly dividing cancerous cells undergo cell death via thymineless death.[32] Calcium folinate provides an exogenous source of reduced folinates and hence stabilises the 5-FU-TS complex, hence enhancing 5-FU's cytotoxicity.[33]

History[edit]

In 1954 Abraham Cantarow and Karl Paschkis found liver tumors absorbed radioactive uracil more readily than normal liver cells. Charles Heidelberger, who had earlier found that fluorine in fluoroacetic acid inhibited a vital enzyme, asked Robert Duschinsky and Robert Schnitzer at Hoffman-La Roche to synthesize fluorouracil.[34] Some credit Heidelberger and Duschinsky with the discovery that 5-fluorouracil markedly inhibited tumors in mice.[35] The original 1957 report[36][37] in Nature has Heidelberger as lead author, along with N. K. Chaudhuri, Peter Danneberg, Dorothy Mooren, Louis Griesbach, Robert Duschinsky, R. J. Schnitzer, E. Pleven, and J. Scheiner.[38]

Natural analogues[edit]

In 2003 it was discovered that a closely related compound[clarification needed] is produced by a marine sponge, Phakellia fusca. This is significant because fluorine-containing organic compounds exist only rarely in nature, and also because manmade anticancer drugs are not frequently found to have analogues in nature.[39]

Interactive pathway map[edit]

Click on genes, proteins and metabolites below to link to respective articles. [§ 1]

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Fluorouracil (5-FU) Activity edit
  1. ^ The interactive pathway map can be edited at WikiPathways: "FluoropyrimidineActivity_WP1601". 

References[edit]

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  2. ^ Brayfield, A., ed. (13 December 2013). "Fluorouracil". Martindale: The Complete Drug Reference. Pharmaceutical Press. Retrieved 16 April 2014. 
  3. ^ "WHO Model List of EssentialMedicines" (PDF). World Health Organization. October 2013. Retrieved 22 April 2014. 
  4. ^ a b c d e f g Rossi, S, ed. (2013). Australian Medicines Handbook (2013 ed.). Adelaide: The Australian Medicines Handbook Unit Trust. ISBN 978-0-9805790-9-3. 
  5. ^ Joag, Madhura G.; Sise, Adam; Murillo, Juan Carlos; Sayed-Ahmed, Ibrahim Osama; Wong, James R.; Mercado, Carolina; Galor, Anat; Karp, Carol L. (2016-03-27). "Topical 5-Fluorouracil 1% as Primary Treatment for Ocular Surface Squamous Neoplasia". Ophthalmology. doi:10.1016/j.ophtha.2016.02.034. ISSN 1549-4713. PMID 27030104. 
  6. ^ a b c d e f "Fluorouracil 50 mg/ml Injection - Summary of Product Characteristics". electronic Medicines Compendium. Hospira UK Ltd. 24 August 2011. Retrieved 24 January 2014. 
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  12. ^ Park H. J., Choi Y. T., Kim I. H., Hah J. C.; A case of reversible dementia associated with depression in a patient on 5-FU or its analogue drugs. J. Korean Neuropsychiatr. Assoc. 1987;30:199–202.
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  27. ^ "Customizing Chemotherapy for Better Cancer Care". MyCare Diagnostics. 
  28. ^ "A Brief History of BSA Dosing". MyCare Diagnostics. 
  29. ^ Porta C, Moroni M, Nastasi G (1994). "Allopurinol mouthwashes in the treatment of 5-fluorouracil-induced stomatitis". Am. J. Clin. Oncol. 17 (3): 246–7. doi:10.1097/00000421-199406000-00014. PMID 8192112. 
  30. ^ a b c Caudle, KE; Thorn, CF; Klein, TE; Swen, JJ; McLeod, HL; Diasio, RB; Schwab, M (December 2013). "Clinical Pharmacogenetics Implementation Consortium guidelines for dihydropyrimidine dehydrogenase genotype and fluoropyrimidine dosing.". Clinical pharmacology and therapeutics 94 (6): 640–5. doi:10.1038/clpt.2013.172. PMID 23988873. 
  31. ^ a b Amstutz, U; Froehlich, TK; Largiadèr, CR (September 2011). "Dihydropyrimidine dehydrogenase gene as a major predictor of severe 5-fluorouracil toxicity.". Pharmacogenomics 12 (9): 1321–36. doi:10.2217/pgs.11.72. PMID 21919607. 
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  33. ^ Álvarez, P.; Marchal, J. A.; Boulaiz, H.; Carrillo, E.; Vélez, C.; Rodríguez-Serrano, F.; Melguizo, C.; Prados, J.; Madeddu, R.; Aranega, A. (February 2012). "5-Fluorouracil derivatives: a patent review". Expert Opinion on Therapeutic Patents 22 (2): 107–123. doi:10.1517/13543776.2012.661413. PMID 22329541. 
  34. ^ Sneader W. (2005). Drug Discovery, p. 255.
  35. ^ Cohen, Seymour (30 January 2008). "50 years ago in cell biology: A virologist recalls his work on cell growth inhibition". The Scientist. 
  36. ^ Chu E (September 2007). "Ode to 5-Fluorouracil". Clinical Colorectal Cancer 6 (9): 609. doi:10.3816/CCC.2007.n.029. 
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  38. ^ Heidelberger C.; Chaudhuri N. K.; Danneberg P.; et al. (March 1957). "Fluorinated pyrimidines, a new class of tumour-inhibitory compounds". Nature 179 (4561): 663–6. doi:10.1038/179663a0. PMID 13418758. 
  39. ^ Xu, Xiao-Hua; Yao, Guang-Min; Li, Yan-Ming; Lu, Jian-Hua; Lin, Chang-Jiang; Wang, Xin; Kong, Chui-Hua (2003-02-01). "5-Fluorouracil derivatives from the sponge Phakellia fusca". Journal of Natural Products 66 (2): 285–288. doi:10.1021/np020034f. ISSN 0163-3864. PMID 12608868. 

External links[edit]