Abstract 1607

Methotrexate is an antifolate agent commonly used for the treatment of lymphoma. The most common adverse effects include mucositis, myelosuppression, hepatic dysfunction and renal toxicities. It inhibits DNA replication by blocking the conversion of 5,10-methylene tetrahydrofolate to 5-methylene tetrahydrofolate by methylene tetrahydrofolate reductase (MTHFR). MTHFR is a key enzyme in folate metabolism and C677T is one of principal polymorphisms implicated in the metabolism of methotrexate.

We aimed to investigate the relationship of the C677T polymorphism with methotrexate concentration in serum as well as methotrexate-associated toxicities. The study cohort included 169 cases treated with regimens containing high dose methotrexate (higher than 1 g/m2) between January 2010 and May 2011. Median age of the patients was 56 years (range, 24–78 years). Concentration of methotrexate was measured daily beginning 48 hours after infusion until the concentration reaches below 0.05 μmol/L.

Forty four cases (26.0%) had a wild genotype of CC, 78 (46.2%) a heterozygous genotype of CT, and 47 (27.8%) a homozygous mutant genotype of TT. Mutant cases of TT had significantly higher MTX serum levels when compared with the other genotypes (Table 1) and required significantly longer time for elimination of methotrexate (p=0.011, Table 2). While hematologic toxicities, hepatotoxicities or number of febrile neutropenic episodes did not differ according to the genopypes, TT genotypes had significantly higher MTX levels and higher incidence of nephrotoxicity. Among them, two required therapeutic plasma exchange for prolonged exposure to high levels of methotrexate.

Table 1.

Concentration of methotrexate at different time points

48 h72 h96 h120 h
Wild-type (CC) 0.38 ± 0.47 0.15 ± 0.20 0.08 ± 0.12 0.09 ± 0.10 
Heterozygous type (CT) 0.32 ± 0.46 0.12 ± 0.20 0.08 ± 0.11 0.07 ± 0.10 
Mutant type (TT) 1.93 ± 5.84 0.92 ± 2.39 0.67 ± 1.25 0.59 ± 0.83 
p-value 0.020 0.011 0.002 0.006 
48 h72 h96 h120 h
Wild-type (CC) 0.38 ± 0.47 0.15 ± 0.20 0.08 ± 0.12 0.09 ± 0.10 
Heterozygous type (CT) 0.32 ± 0.46 0.12 ± 0.20 0.08 ± 0.11 0.07 ± 0.10 
Mutant type (TT) 1.93 ± 5.84 0.92 ± 2.39 0.67 ± 1.25 0.59 ± 0.83 
p-value 0.020 0.011 0.002 0.006 
*

Data expressed as mean ± SEM

View Large

Table 2.

Duration (days) to serum concentration of methotrexate < 0.05 μmol/L

MTHFR C677T
CCCTTTp-value
Duration until methotrexate level < 0.05 μmol/L (days) 4.89 ± 2.95 4.35 ± 2.05 7.66 ± 9.00 0.011 
MTHFR C677T
CCCTTTp-value
Duration until methotrexate level < 0.05 μmol/L (days) 4.89 ± 2.95 4.35 ± 2.05 7.66 ± 9.00 0.011 
*

Data expressed as mean ± SEM

View Large

Table 3.

MTHFR polymorphisms vs. grade 3/4 toxicities

Grades 3/4 toxicityMTHFR C677T
CC (%)CT (%)TT (%)p-value
Hb 27.3 17.9 34.0 0.431 
WBC 52.3 61.5 53.2 0.950 
PLT 45.5 51.3 53.2 0.465 
AST 2.3 10.3 8.5 0.277 
ALT 11.4 11.5 10.6 0.911 
Total bilirubin 6.8 1.3 4.3 0.532 
Creatinine* 0 1.3 10.6 0.006 
ANC 47.7 62.8 68.1 0.050 
FN episodes** 31.8 37.2 42.6 0.291 
Mucositis 15.9 14.1 17.0 0.650 
Grades 3/4 toxicityMTHFR C677T
CC (%)CT (%)TT (%)p-value
Hb 27.3 17.9 34.0 0.431 
WBC 52.3 61.5 53.2 0.950 
PLT 45.5 51.3 53.2 0.465 
AST 2.3 10.3 8.5 0.277 
ALT 11.4 11.5 10.6 0.911 
Total bilirubin 6.8 1.3 4.3 0.532 
Creatinine* 0 1.3 10.6 0.006 
ANC 47.7 62.8 68.1 0.050 
FN episodes** 31.8 37.2 42.6 0.291 
Mucositis 15.9 14.1 17.0 0.650 
*

grade 2 toxicity

**

Adverse event positive

View Large

Our data shows that cases with TT genotype for the MTHFR C677T polymorphism are associated with methotrexate-related renal toxicities. When high dose methotrexate is administered to the patients with TT genoptype, close monitoring for the nephrotoxicity seems to be required.

Disclosures:

No relevant conflicts of interest to declare.

Topics:
lymphoma, methotrexate, methylenetetrahydrofolate reductase (nadph2), polymorphism, toxic effect, chief complaint, mucositis, nephrotoxicity, adverse effects, adverse event

Author notes

*

Asterisk with author names denotes non-ASH members.

© 2011 by The American Society of Hematology
2011
Sign in via your Institution