Hydroxyurea Pharmacokinetic Evaluation in Patients with Sickle Cell Disease

Abstract

Background: Hydroxyurea (HU), also known as hydroxycarbamide, is an oral ribonucleotide reductase inhibitor. In 1999, the United States Food and Drug Administration (FDA) approved HU for the treatment of sickle cell disease (SCD). Since then, it has become the cornerstone in the management of SCD patients, helping to reduce vaso-occlusive crises, acute chest syndrome, the need for blood transfusions, hospitalizations and mortality. There is considerable variability among individuals in HU pharmacokinetic (Pk) parameters that can influence treatment efficacy and toxicity. The objective of this work is part of a clinical study aimed at investigating HU Pk and determining the optimal sampling time to estimate the Area Under the Curve (AUC) in SCD patients. Methods: HU plasma concentration in 80 patients at various time points (2, 4, 6, 24 h) following a 48-h drug washout was quantified using High-Pressure Liquid Chromatography (HPLC) coupled with an ultraviolet (UV) detection method previously described in the literature and adapted to new conditions with partial modifications. Results: The mean HU administered dose was 19.5 ± 5.1 mg/kg (range: 7.7-37.5 mg/kg). The median AUC quantified in plasma patients was 101.3 mg/L/h (Interquartile Range (IQR): 72.5-355.9) and it was not influenced by the weight-based dose. However, there was a strong positive correlation between AUC and Body Mass Index (BMI) as well as dose per Body Surface Area (BSA). Along with a three-point approach for AUC determination present in the literature, we show results obtained from a four-point sampling strategy, which is more useful and effective for better optimizing dose escalation to the maximum tolerated dose (MTD). Moreover, we observed that most patients achieved the maximum HU plasma concentration two hours after drug administration, regardless of age differences. Conclusions: HU treatment, which represents a milestone in the treatment of SCD due to its ability to reduce disease complications and improve patients' quality of life, requires careful monitoring to optimize the individual dose for saving potential side effects and/or adverse events.

Keywords: area under the curve; high-pressure liquid chromatography; maximum tolerated dose; sex; therapeutic drug monitoring; variability.

Figure 1

Example of HU calibration curve.

Figure 2

Example of HU peaks. Representative chromatograms of (a) blank plasma sample supplemented with Xan; (b) blank plasma sample supplemented with Xan and Me-U; (c) the lowest point of the calibration curve: HU 0.625 μg/mL; (d) the highest point of the calibration curve: HU 40 μg/mL.

Figure 3

HU AUCs expressed by the median values obtained for each sampling point (0 prior to drug administration; 2, 4, 6, 24 h after drug intake). (a) Median AUC calculated for all patients (N = 80). (b) Median AUC calculated for female patients (N = 42). (c) Median AUC calculated for male patients (N = 38).