title: Changes in the clearance of total and unbound etoposide in patients with liver dysfunction.
abstract: The disposition of total and non-protein-bound etoposide was investigated in 21 cancer patients receiving etoposide and cisplatin combination chemotherapy. Etoposide plasma concentrations were determined using a specific high-performance liquid chromatography (HPLC) method, and etoposide plasma protein binding was determined by equilibrium dialysis. The patients had a wide range of renal function (creatinine clearance, 32 to 159 mL/min/m2) and hepatic function (total bilirubin range, 0.3 to 21.5 mg/dL; aspartate aminotransferase [AST] range, 14 to 415 IU/L; serum albumin range, 2.7 to 4.1 g/dL). The mean etoposide total systemic clearance was not different in 15 patients with total bilirubin less than 1.0 mg/dL versus six patients with total bilirubin 1.1 to 21.5 mg/dL (18.7 +/- 5.9 mL/min/m2 v 26.4 +/- 10.7 mL/min/m2; t-test P = .06), with a trend toward higher total clearance in the patients with abnormal bilirubin values. However, the mean clearance of unbound etoposide was significantly lower in patients with increased total bilirubin (220 +/- 90 mL/min/m2 v 135 +/- 61 mL/min/m2; t-test P = .027). The fraction of etoposide unbound (fu) in plasma was significantly higher in patients with increased bilirubin (9% +/- 3% v 27% +/- 15%; t-test P = .002), explaining the trend toward higher total clearance in these patients. Etoposide clearance (total or unbound) in the 14 patients with measurable hepatic metastases was not different from the clearance in the seven patients without hepatic metastases. This study provides an explanation for why patients with increased bilirubin do not have lower total systemic clearance of etoposide, and indicates that such patients have a higher exposure to unbound etoposide. The results of ongoing pharmacodynamic studies of total and unbound etoposide in patients with increased bilirubin will determine the clinical relevance of altered etoposide protein binding.
authors.affiliation: Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee, Memphis 38163.
authors.forename: C F
authors.initials: CF
authors.lastname: Stewart
authors.forename: S G
authors.initials: SG
authors.lastname: Arbuck
authors.forename: R A
authors.initials: RA
authors.lastname: Fleming
authors.forename: W E
authors.initials: WE
authors.lastname: Evans
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D001663:Bilirubin / Q000097:blood; D002851:Chromatography, High Pressure Liquid; D002945:Cisplatin / Q000008:administration & dosage; D003404:Creatinine / Q000097:blood; D005047:Etoposide / Q000008:administration & dosage / Q000097:blood / Q000493:pharmacokinetics*; D005260:Female; D006801:Humans; D008099:Liver / Q000378:metabolism* / Q000503:physiopathology; D008111:Liver Function Tests; D008297:Male; D009369:Neoplasms / Q000097:blood* / Q000188:drug therapy / Q000503:physiopathology; D011485:Protein Binding; D012044:Regression Analysis
chemical_list: D005047:Etoposide; D003404:Creatinine; D002945:Cisplatin; D001663:Bilirubin