Summary
Abstract
Capecitabine is an orally administered fluoropyrimidine which is selectively activated in tumour tissue to the active moiety fluorouracil and is cytotoxic through inhibition of DNA synthesis.
In patients with advanced or metastatic colorectal cancer, first-line therapy with intermittent capecitabine achieved significantly higher objective tumour response rates than therapy with fluorouracil plus leucovorin in pooled analysis. Response rates were also higher in patients pretreated in the adjuvant setting and whose primary site of metastasis was the lung. However, no significant differences between the two treatment groups were seen in the time to disease progression, time to treatment failure or overall survival.
Preliminary data suggest response may be improved by combining capecitabine with other anticancer therapies such as oxaliplatin, irinotecan and radiotherapy.
Capecitabine in therapeutic dosage regimens generally has acceptable tolerability. Diarrhoea and hand-and-foot syndrome are the major dose-limiting toxicities associated with capecitabine therapy, with adverse effects generally of a gastrointestinal nature. Overall, diarrhoea, stomatitis, nausea and alopecia were significantly less common with capecitabine than with bolus fluorouracil and leucovorin. In addition, capecitabine recipients experienced significantly less myelosuppression, although more capecitabine recipients discontinued therapy because of adverse events. Importantly, patients spent less time in hospital after capecitabine than after bolus fluorouracil and leucovorin therapy, and the oral route of administration of capecitabine is likely to be preferred.
In conclusion, capecitabine has shown superior tumour response and less myelosuppression, although more grade 3 hand-and-foot syndrome, in comparison with the ‘Mayo Clinic’ regimen of fluorouracil therapy, but is unlikely to improve survival. Significantly, its oral route of administration is likely to be preferred by patients. Future strategies to improve patient response may involve selection of those patients likely to respond best to capecitabine, through determination of relevant enzyme levels and combination of capecitabine with various antineoplastic agents. Data on the effect of the drug on quality of life would help establish its role. In the meantime, capecitabine appears to offer an effective and more convenient alternative to fluorouracil as first-line monotherapy for the treatment of metastatic colorectal cancer.
Pharmacodynamic Properties
Capecitabine is a specifically designed target-specific oral fluoropyrimidine which is converted to fluorouracil in tumour tissue via a three-step enzymatic cascade. It effects antineoplastic activity via inhibition of DNA synthesis. Both thymidine phosphorylase (TP) and cytidine deaminase, enzymes required for capecitabine activation, show increased activity in tumour tissue from patients with various types of cancer compared with healthy tissue. High intratumoural concentrations of fluorouracil are observed following oral capecitabine administration. Ex vivo, fluorouracil concentrations in human colorectal tumour tissue are approximately 3-fold higher than those in adjacent healthy tissue.
The antineoplastic activity of capecitabine has been demonstrated over a wide range of human colorectal cancer xenograft systems. In vivo, greater antitumour efficacy (assessed by tumour growth inhibition) has been demonstrated over a range of dosages in comparison with both fluorouracil and the oral fluoropyrimidine tegafur/uracil in fluorouracil-sensitive and some refractory tumours. Capecitabine has a therapeutic index of >6.4 in the HCT116 xenograft model. The activity and expression of TP in tumours are correlated with the sensitivity of the tumour to capecitabine and the promotion of tumour growth, respectively.
The activity and the ratio of TP to dihydropyrimidine dehydrogenase are measures that discriminate between capecitabine-sensitive and refractory tumours in xenograft models. Addition of the TP up-regulators paclitaxel, docetaxel, cyclophosphamide, mitomycin and x-ray irradiation to capecitabine increases tumour inhibition compared with capecitabine alone.
Pharmacokinetic Properties
Capecitabine undergoes rapid and extensive enzymatic conversion to a number of intermediary metabolites. The absorption pharmacokinetics of capecitabine and its metabolites appear dose proportional. Maximum plasma capecitabine concentrations (Cmax) of ≈4 mg/L and area under the concentration-time curve (AUC) values of ≈6 mg/L h are seen following oral administration of capecitabine 1250 mg/m2. Plasma capecitabine concentrations decrease rapidly with an elimination half-life of 0.5 to 0.7 hours. Peak concentrations of the primary excretory metabolite α-fluoro-β-alanine (FBAL) occur approximately 5 hours after administration of capecitabine. The metabolites are principally excreted via the kidneys, with 3% of an administered dose excreted as capecitabine. Accumulation of capecitabine has not been reported after repeated doses. The estimated oral bio-availability of capecitabine is nearly 100%.
The pharmacokinetic disposition of capecitabine is not significantly affected by gender or mild to moderate hepatic dysfunction.
Capecitabine taken without food increases both Cmax and AUC and decreases the time to Cmax (tmax), while capecitabine pharmacokinetics are not affected by magnesium hydroxide/aluminium hydroxide to any clinically significant extent.
Therapeutic Use
Capecitabine administered intermittently (1250 mg/m2 twice daily for 2 weeks in a 3-week cycle) has been investigated in adult patients as treatment for advanced or metastatic colorectal adenocarcinoma. Two large, well-designed phase III trials have compared capecitabine monotherapy with the standard fluorouracil-based ‘Mayo Clinic’ regimen (425 mg/m2/day fluorouracil + 20 mg/m2/day leucovorin days 1 to 5 in a 4-week cycle). Some information is available from a prospectively defined integrated analysis of these two identical studies.
In patients with advanced or metastatic colorectal cancer, capecitabine mono-therapy as first-line treatment significantly increased the objective response rate compared with fluorouracil and leucovorin therapy alone; objective response rates were 22 versus 13% (p < 0.0001). In patients pretreated in the adjuvant setting, the overall response rate was doubled in those receiving capecitabine and tripled in patients whose primary site of metastasis was the lung compared with fluorouracil and leucovorin (21.1 vs 9.0% and 33.3 vs 10.3%, respectively). Capecitabine was at least equivalent to the Mayo Clinic regimen with regard to time to disease progression (median 4.6 vs 4.7 months), time to treatment failure (median 4.2 vs 3.6 months) or overall survival duration (median 12.9 vs 12.8 months).
In a randomised phase II study, intermittent capecitabine therapy achieved overall response rates (24%) which were similar to those achieved with continuous capecitabine therapy (21%) and capecitabine in combination with leucovorin (23%) in patients previously untreated for metastatic colorectal cancer. Rates of disease stabilisation were slightly higher in those receiving intermittent and combination capecitabine than in those receiving continuous capecitabine.
Phase I and II studies of first-line treatment with capecitabine in combination with other antineoplastic therapies, notably oxaliplatin, have shown encouraging response rates.
Tolerability
The tolerability profile of capecitabine is typical of infusional fluoropyrimidines and adverse effects are primarily of a gastrointestinal nature. Dose reduction is most commonly indicated for diarrhoea and hand-and-foot syndrome.
Overall, diarrhoea, stomatitis, nausea and alopecia occurred significantly less often in patients receiving capecitabine than in patients administered bolus fluorouracil and leucovorin therapy. Grade 3 or 4 hyperbilirubinaemia and hand- and-foot syndrome occur more frequently in patients receiving capecitabine; grade 3 or 4 stomatitis, neutropenic fever and sepsis were seen less often.
Importantly, patients spent less time in hospital after capecitabine than after fluorouracil therapy, and the oral route of administration of capecitabine is likely to be preferred.
Acceptable toxicity was seen when capecitabine was combined with other antineoplastic therapies including oxaliplatin, irinotecan or radiotherapy in phase I and II studies.
Dosage and Administration
Capecitabine is approved for use throughout the European Union, US, Canada and Australia as a first-line therapy for advanced or metastatic colorectal cancer. The recommended dosage regimen of capecitabine is 1250 mg/m2 twice daily for 14 days in a 3-week cycle to be administered orally after food.
The dosage should be adjusted according to tolerability and the drug is contra-indicated in patients who are pregnant, have severe renal impairment [creatinine clearance <30 ml/min (1.8 L/h)] and those with known hypersensitivity to fluorouracil. The starting dosage should also be reduced to ≈940 mg/m2 in patients with moderate renal impairment [creatinine clearance 30 to 50 ml/min (1.8 to 3 L/h)].
Haemostatic parameters should be closely monitored in those additionally receiving coumarin-derivative anticoagulants because of an increased risk for bleeding. Patients receiving concomitant phenytoin should be regularly monitored for increased plasma phenytoin concentrations.
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References
Pisani P, Parkin DM, Bray F, et al. Estimates of the worldwide mortality from 25 cancers in 1990. Int J Cancer 1999; 83: 18–29
Parkin DM, Pisani P, Ferlay J. Estimates of the worldwide incidence of 25 major cancers in 1990. Int J Cancer 1999; 80: 827–41
Boyle P, Langman JS. ABC of colorectal cancer: epidemiology. BMJ 2000; 321: 805–8
National Institutes of Health. Colon cancer r(PDQ): treatment — health professionals [online]. Available from URL: http://www.cancernet.nci.nih.gov [Accessed 2000 Oct 31]
Colorectal Cancer Collaborative Group. Palliative chemotherapy for advanced colorectal cancer: systematic review and meta-analysis. BMJ 2000; 321: 531–5
Ignoffo RJ. Novel oral fluoropyrimidines in the treatment of metastatic colorectal cancer. Am J Health Syst Pharm 1999 Dec 1; 56: 2417–28
Del Vecchio M, Procopio G, Cassata A, et al. Fluoropyrimidines in the treatment of advanced neoplastic diseases: role and advantages of UFT. Tumori 1999; 85(1): 6–11
Shimma N, Umeda I, Arasaki M, et al. The design and synthesis of a new tumor-selective fluoropyrimidine carbamate, capecitabine. Bioorg Med Chem Lett 2000; 8: 1697–706
Miwa M, Ura M, Nishida M, et al. Design of a novel oral fluoropyrimidine carbamate, capecitabine, which generates 5-fluorouracil selectively in tumours by enzymes concentrated in human liver and cancer tissue. Eur J Cancer 1998; 34(8): 1274–81
Sobrero A, Guglielmi A, Grossi F, et al. Mechanism of action of fluoropyrimidines: relevance to the new developments in colorectal cancer chemotherapy. Semin Oncol 2000; 27(5): 72–7
Ishitsuka H. Capecitabine: preclinical pharmacology studies. Invest New Drugs 2000; 18(4): 343–54
Dooley M, Goa KL. Capecitabine. Drugs 1999 Jul; 58: 69–76
Ishikawa T, Sekiguchi F, Fukase Y, et al. Positive correlation between the efficacy of capecitabine and doxifluridine and the ratio of thymidine phosphorylase to dihydropyrimidine dehydrogenase activities in tumors in human cancer xenografts. Cancer Res 1998 Feb 15; 58: 685–90
Cao S, Lu K, Ishitsuka H, et al. Antitumor efficacy of capecitabine against fluorouracil-sensitive and -resistant tumors [abstract]. 33rd Annual Meeting of the American Society of Clinical Oncology; 1997 May 17: Denver (CO), 226
Bicknell R, Harris AL. Mechanisms and therapeutic implications of angiogenesis. Curr Opin Oncol 1996; 8(1): 60–5
Ishikawa T, Utoh M, Sawada N, et al. Tumor selective delivery of 5-fluorouracil by capecitabine, a new oral fluoropyrimidine carbamate, in human cancer xenografts. Biochem Pharmacol 1998; 55: 1091–7
Schüller J, Cassidy J, Dumont E, et al. Preferential activation of capecitabine in tumor following oral administration to colorectal cancer patients. Cancer Chemother Pharmacol 2000; 45: 291–7
Sawada N, Ishikawa T, Fukase Y, et al. Induction of thymidine phosphorylase activity and enhancement of capecitabine efficacy by Taxol/Taxotere in human cancer xenografts. Clin Cancer Res 1998 Apr; 4: 1013–9
Sawada N, Ishikawa T, Sekiguchi F, et al. X-ray irradiation induces thymidine phosphorylase and enhances the efficacy of capecitibine (Xeloda) in human cancer xenografts. Clin Cancer Res 1999; 5: 2948–53
Mackean M, Planting A, Twelves C, et al. Phase I and pharmalogic study of intermittent twice-daily oral therapy with capecitabine in patients with advanced and/or metastatic cancer. J Clin Oncol 1998; 16(9): 2977–85
Pronk LC, Vasey P, Sparreboom A, et al. A phase I and pharmacokinetic study of the combination of capecitabine and docetaxel in patients with advanced solid tumours. Br J Cancer 2000; 83: 22–9
Budman DR, Meropol NJ, Reigner B, et al. Preliminary studies of a novel oral fluoropyrimidine carbamate: capecitabine. J Clin Oncol 1998 May; 16(5): 1795–802
Reigner B, Blesch K, Weidekamm E. Clinical pharmacokinetics of capecitabine. Clin Pharmacokinet 2001; 40(2): 85–104
Reigner B, Verweij J, Dirix L, et al. Effect of food on the pharmacokinetics of capecitabine and its metabolites following oral administration in cancer patients. Clin Cancer Res 1998 Apr; 4: 941–8
Judson IR, Beale PJ, Trigo JM, et al. A human capecitabine excretion balance and pharmacokinetic study after administration of a single oral dose of 14 C-labelled drug. Invest New Drugs 1999; 17: 49–56
Roche Laboratories Inc, Nutley, NJ. Xeloda® (capecitabine) tablets. Prescribing information [online]. Available from URL: www.rocheusa.com/products/xeloda/pionly.htm [Accessed 2001 Oct 15]
Twelves C, Glynne-Jones R, Cassidy J, et al. Effect of hepatic dysfunction due to liver metastases on the pharmacokinetics of capecitabine and its metabolites. Clin Cancer Res 1999 Jul; 5: 1696–702
Reigner B, Clive S, Cassidy J, et al. Influence of the antacid Maalox on the pharmacokinetics of capecitabine in cancer patients. Cancer Chemother Pharmacol 1999; 43(4): 309–15
Kolesar JM, Johnson CL, Freeberg BL, et al. Warfarin-5-FU interaction: a consecutive case series. Pharmacotherapy 1999; 19: 1445–9
Hoff P, Ansari R, Batist G, et al. Comparison of oral capecitabine versus intravenous fluorouracil plus leucovorin as first-line treatment in 605 patients with metastatic colorectal cancer: results of a randomized phase III study. J Clin Oncol 2001; 19: 2282–92
van Cutsem E, Twelves C, Cassidy J, et al. Oral capecitabine compared with intravenous 5-fluorouracil plus leucovorin in patients with metastatic colorectal cancer: results of a large phase III study. J Clin Oncol 2001; 19: 4097–106
Hoff P, Abbruzzese JL, Medgyesy D, et al. A phase II study of Xeloda (capecitabine) in patients with metastatic colorectal cancer demonstrating progression on 5-FU therapy [abstract 256]. 36th Annual Meeting of the American Society of Clinical Oncology; 2000 May 20–23; New Orleans, LA
Van Cutsem E, Findlay M, Osterwalder B, et al. Capecitabine, an oral fluoropyrimidine carbamate with substantial activity in advanced colorectal cancer: results of a randomized phase II study. J Clin Oncol 2000 Mar; 18: 1337–45
Schleucher N, Tewes M, Achterrath W, et al. Extended phase I study of capecitabine in combination with a weekly schedule of irinotecan as first-line chemotherapy in metastatic colorectal cancer [abstract 1073]. 11th European Cancer Conference; 2001 Oct 21–25; Lisbon, Portugal
Dunst J, Reese T, Frings S. Phase I study of capecitabine with simultaneous radiotherapy in rectal cancer [abstract 592]. 37th Annual Meeting of the American Society of Clinical Oncology (ASCO); 2001 May 12–15, San Francisco (CA)
Kerr DJ, Ten Bokkel Huinink WW, Bakker J, et al. CPT-11 in combination with capecitabine as first line chemotherapy for metastatic colorectal cancer (MCRC): preliminary results of a phase I/II study [abstract]. 11th European Cancer Conference; 2001 Oct 21–25; Lisbon, Portugal
Delord JP, Pierga JY, Bertheault-Cvitkovic F, et al. Dose escalation and pharmacokinetic study of capecitabine (Xeloda®) and irinotecan (CPT-11) in gastro-intestinal tumours [abstract 272]. 11th European Cancer Conference; 2001 Oct 21–25; Lisbon, Portugal
Twelves C. Capecitabine in combination with oxaliplatin as first-line therapy for patients with advanced or metastatic colorectal cancer: preliminary results of an international multi-centre phase II study [poster presentation]. 11th European Cancer Conference;2001 Oct 21–25; Lisbon, Portugal
Miller AB, Hoogstraten B, Staquet M, et al. Reporting results of cancer treatment. Cancer 1981; 47: 207–14
Hoff P. Capecitabine as first-line treatment for colorectal cancer (CRC): integrated results of 1207 patients (pts) from 2 randomized, phase III studies. On behalf of the Capecitabine CRC Study Group [abstract]. Ann Oncol 2000; 11 Suppl. 4: 60
Hoff P. Capecitabine as first-line treatment for metastatic colorectal cancer (CRC): integrated results of 1207 patients (pts) from 2 randomized, phase III studies [poster]. 25th ESMO Congress; 2000 Oct 13–17; Hamburg, Germany
Cassidy J, Dirix L, Bissett D, et al. A phase I study of capecitabine in combination with oral leucovorin in patients with intractable solid tumors. Clin Cancer Res 1998; 4: 2755–61
Cassidy J, Twelves C. Effective dose-modification (DM) scheme for the management of toxicities with capecitabine therapy: data from metastatic colorectal cancer (mCRC) phase III trials. Capecitabine CRC Study Group [poster]. 25th ESMO Congress; 13–17 Oct 2000; Hamburg, Germany
Walkholm B, Fraunfelder FT, Henner WD. Severe ocular irritation and corneal deposits associated with capecitabine use [letter]. N Engl J Med 2000; 343: 740–1
Twelves C, van Cutsem E, Hieke K, et al. Medical resource use in a phase III trial (SO 14796) of Xeloda® (capecitabine) in previously untreated advanced/metastatic colorectal cancer [abstract]. Eur J Cancer 1999 Sep; 35 Suppl. 4: S68–69
Roche. Roche receives European approval for Xeloda, the first chemotherapy for the treatment of metastatic colorectal cancer [media release]. Available from URL: http://www.roche.com [Accessed 2001 Feb 26]
World Health Organisation. WHO World Health Report 2000 [online]. Available from URL: http://www.who.int/whosis [Accessed 2000 Oct 30]
Hoff PM, Royce M, Medgyesy D, et al. Oral fluoropyrimidines. Semin Oncol 1999 Dec; 26: 640–6
Liu G, Franssen E, Fitch MI, et al. Patient preferences for oral versus intravenous palliative chemotherapy. J Clin Oncol 1997; 15: 110–5
Gunasekara NS, Faulds D. Raltitrexed: a review of its pharmacological properties and clinical efficacy in the management of advanced colorectal cancer. Drugs 1998 Mar; 55: 423–35
Wiseman LR, Markham A. Irinotecan: a review of its pharmacological properties and clinical efficacy in the management of advanced colorectal cancer. Drugs 1996 Oct; 52: 606–23
Culy CR, Clemett D, Wiseman LR. Oxaliplatin: a review of its pharmacological properties and clinical efficacy in metastatic colorectal cancer and its potential in other malignancies. Drugs 2000; 60(4): 895–924
Buroker TR, O’Connell MJ, Wieand HS, et al. Randomized comparison of two schedules of fluorouracil and leucovorin in the treatment of advanced colorectal cancer. J Clin Oncol 1994; 12: 14–20
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Various sections of the manuscript reviewed by: S. Kahlert, Ludwig-Maximilians-Universität, Klinikum Grosshadern, Munich, Germany; D. Papamichael, Department of Medical Oncology, BOC Oncology Centre, Nicosia, Cyprus; H.-J. Schmoll, Department of Haematology and Oncology, Martin-Luther Universität, Halle/Saale, Germany; C. Twelves, Cancer Research Campaign Department of Medical Oncology, University of Glasgow, Glasgow, Scotland; W. R. Wilson, Auckland Cancer Society Research Centre, University of Auckland, Auckland, New Zealand; J. R. Zalcberg, Department of Medical Oncology and Haematology, Peter MacCallum Cancer Institute, Melbourne, Victoria, Australia
Data Selection
Sources: Medical literature published in any language since 1983 on Capecitabine, identified using AdisBase (a proprietary database of Adis International, Auckland, New Zealand), Medline and EMBASE. Additional references were identified from the reference lists of published articles. Bibliographical information, including contributory unpublished data, was also requested from the company developing the drug.
Search strategy: AdisBase search terms were ‘Capecitabine’ and ‘Colorectal-Cancer’ or ‘Capecitabine adj PK/PD’. Medline search terms were ‘Capecitabine’ or ‘RO 09 1978’ and ‘Colorectal-Neoplasms’. EMBASE search terms were ‘Capecitabine’ or ‘RO 09 1978’ and ‘Colorectal-Cancer’. Searches were last updated 12 Oct, 2001.
Selection: Studies in patients with colorectal cancer who received capecitabine. Inclusion of studies was based mainly on the methods section of the trials. When available, large, well controlled trials with appropriate statistical methodology were preferred. Relevant pharmacodynamic and pharmacokinetic data are also included.
Index terms: Capecitabine, colorectal cancer, tolerability, pharmacodynamics, pharmacokinetics, therapeutic use.
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McGavin, J.K., Goa, K.L. Capecitabine. Drugs 61, 2309–2326 (2001). https://doi.org/10.2165/00003495-200161150-00015
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DOI: https://doi.org/10.2165/00003495-200161150-00015