The effect of ifosfamide and its metabolites on intracellular glutathione levels in vitro and in vivo

doi:10.1016/0006-2952(89)90419-X

Biochemical Pharmacology

Volume 38, Issue 11, 1 June 1989, Pages 1835-1840

https://doi.org/10.1016/0006-2952(89)90419-X Get rights and content

Abstract

The effect of ifosfamide and its metabolites on intracellular levels of glutathione in P388 cells in vitro has been studied. It is demonstrated that glutathione depletion occurs only in the presence of 4-hydroperoxyifosfamide and chloroacetaldehyde. In contrast isophosphoramide mustard had no effect on glutathione levels in intact cells. The concentration of 4-hydroperoxyifosfamide required to reduce glutathione levels by 50% was approximately 1 mM and this represents a concentration far in excess of that achievable in patients receiving the drug. However the concentration of chloroacetaldehyde (approximately 100 μM) required to reduce intracellular levels of glutathione to a similar extent is attained in patients receiving ifosfamide. The glutathione levels in lymphocytes isolated from a patient undergoing an eight hour infusion of ifosfamide showed a marked decrease to about 30% of their original value. We conclude that ifosfamide causes glutathione depletion in vivo and the majority of this can be accounted for by the production of chloroacetaldehyde.

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In this review we trace the passage of fundamental ideas through 20^th century cancer research that began with observations on mustard gas toxicity in World War I. The transmutation of these ideas across scientific and national boundaries, was channeled from chemical carcinogenesis labs in London via Yale and Chicago, then ultimately to the pharmaceutical industry in Bielefeld, Germany. These first efforts to checkmate cancer with chemicals led eventually to the creation of one of the most successful groups of cancer chemotherapeutic drugs, the oxazaphosphorines, first cyclophosphamide (CP) in 1958 and soon thereafter its isomer ifosfamide (IFO). The giant contributions of Professor Sir Alexander Haddow, Dr. Alfred Z. Gilman & Dr. Louis S. Goodman, Dr. George Gomori and Dr. Norbert Brock step by step led to this breakthrough in cancer chemotherapy. A developing understanding of the metabolic disposition of ifosfamide directed efforts to ameliorate its side-effects, in particular, ifosfamide-induced encephalopathy (IIE). This has resulted in several candidates for the encephalopathic metabolite, including 2-chloroacetaldehyde, 2-chloroacetic acid, acrolein, 3-hydroxypropionic acid and S-carboxymethyl-L-cysteine. The pros and cons for each of these, together with other IFO metabolites, are discussed in detail. It is concluded that IFO produces encephalopathy in susceptible patients, but CP does not, by a “perfect storm,” involving all of these five metabolites. Methylene blue (MB) administration appears to be generally effective in the prevention and treatment of IIE, in all probability by the inhibition of monoamine oxidase in brain potentiating serotonin levels that modulate the effects of IFO on GABAergic and glutamatergic systems. This review represents the authors’ analysis of a large body of published research.
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These results are consistent with the known in vitro antineoplastic activity of 4-HC and 4-HI, active metabolic products of cyclophosphamide and ifosfamide, respectively [19,20]. 4-HC and 4-HI are known to be partly metabolized through GSH conjugation in human cells [21–23]. Conversely, cyclophosphamide and ifosfamide did not show significant activity.
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Chronic ifosfamide toxicity: Kidney pathology and pathophysiology
2014, American Journal of Kidney Diseases
Citation Excerpt :
Tubular epithelial CYP2B6 can inactivate ifosfamide by N-dechloroethylation to release chloroacetaldehyde, a compound without significant antitumor activity, but potentially responsible for many of ifosfamide's neurotoxic and nephrotoxic side effects.12 Tubular epithelial cells may be able to detoxify a limited quantity of chloroacetaldehyde,13 but higher concentrations lead to depletion of intracellular glutathione14 and adenosine triphosphate levels,15 resulting in impaired tubular epithelial cell function and acute injury. In this way, hOCT2-mediated transport of ifosfamide into kidney tubular epithelial cells followed by in situ cytochrome-mediated modification results in the localized generation of high levels of genotoxic nitrogen mustards and tubulotoxic chloroacetaldehyde.
Ifosfamide is a nitrogen mustard alkylating agent used as both a first-line and a salvage chemotherapeutic agent in the treatment of testicular germ cell tumors, various sarcomas, carcinomas, and some lymphomas. A well-known complication of ifosfamide therapy is transient acute kidney injury. However, in a minority of patients, the reduction in kidney function is progressive and permanent, sometimes occurring long after exposure to ifosfamide. Scattered reports have described the pathologic findings in kidneys permanently affected by ifosfamide toxicity. We present the findings of an illustrative case and review the pathology and molecular mechanisms of long-term ifosfamide toxicity with implications for personalized medicine.
The glycine deportation system and its pharmacological consequences
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The glycine deportation system is an essential component of glycine catabolism in man whereby 400 to 800 mg glycine per day are deported into urine as hippuric acid. The molecular escort for this deportation is benzoic acid, which derives from the diet and from gut microbiota metabolism of dietary precursors. Three components of this system, involving hepatic and renal metabolism, and renal active tubular secretion help regulate systemic and central nervous system levels of glycine. When glycine levels are pathologically high, as in congenital nonketotic hyperglycinemia, the glycine deportation system can be upregulated with pharmacological doses of benzoic acid to assist in normalization of glycine homeostasis. In congenital urea cycle enzymopathies, similar activation of the glycine deportation system with benzoic acid is useful for the excretion of excess nitrogen in the form of glycine. Drugs which can substitute for benzoic acid as substrates for the glycine deportation system have adverse reactions that may involve perturbations of glycine homeostasis. The cancer chemotherapeutic agent ifosfamide has an unacceptably high incidence of encephalopathy. This would appear to arise as a result of the production of toxic aldehyde metabolites which deplete ATP production and sequester NADH in the mitochondrial matrix, thereby inhibiting the glycine deportation system and causing de novo glycine synthesis by the glycine cleavage system. We hypothesize that this would result in hyperglycinemia and encephalopathy. This understanding may lead to novel prophylactic strategies for ifosfamide encephalopathy. Thus, the glycine deportation system plays multiple key roles in physiological and neurotoxicological processes involving glycine.
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Below a certain age protocols in pediatric oncology on cytostatic drug therapy advise use, of other parameters such as weight for dosing; this instead of the most conventional parameter, i.e. body surface area. In infants it is not uncommon that additional reductions are put on top of this for each cytostatic drugs to be administered. The rationale behind this is often lacking. Differences related to the ontogeny of absorption, distribution, metabolism and excretion are often not mentioned. Considering characteristics, such as lipophilia, ionization in relation to pH and size of the molecule and linking these characteristics with age related shifts in the gastrointestinal tract, composition of the body and renal function; predictions on pharmacokinetics (PK) in these infants can to a certain extent be made. More difficult are the shifts in activity of phase I and II enzymes, which are often not known for a specific product. In this review data on the ontogeny of relevant pharmacokinetic pathways in relation to the various cytostatic drugs and data from pharmacokinetic (PK) studies in infants are presented.
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Citation Excerpt :
IFO was chosen to be combined with PLD for its better therapeutic index and lower hematologic toxicity than cyclophosphamide. Continuous infusion IFO was preferred to short injection, because induces less renal, hematologic, and neurologic toxicities [35,36]. Our study results showed that the combination of IFO and PLD is feasible, with no limited toxicity.
To evaluate the efficacy of pegylated liposomal doxorubicin (PLD) and continuous infusion ifosfamide (IFO) in ovarian cancer patients who relapse within 1 year after first-line paclitaxel-platinum-based chemotherapy.
Patients were stratified according to treatment-free interval (TFI) (< or ≥ 6 months). PLD (40 mg/m², day 1), IFO (1700 mg/m², infusion days 1–3), and mesna were given every 28 days for 6–9 cycles. Primary endpoint was objective response rate (ORR). Secondary endpoints were response duration, progression free survival (PFS), overall survival (OS), and toxicity.
There were 98 evaluable patients (58%, TFI < 6 months). Median number of cycles was 5 (range: 1–9). The frequency of grade 3/4 anemia, thrombocytopenia, and neutropenia was 7%, 3%, and 48%, respectively; febrile neutropenia was 3%. A low rate of grade 3/4 non-hematologic toxicities was reported, including nausea/vomiting (3/4%), hand-foot syndrome (2%), and mucositis (2%). The ORR was 28% (41% and 19% in patients with TFI ≥ 6, or < 6 months, respectively); rate of disease stabilization was 26%; response duration and median OS were 6 (2.4–26) and 14 (1–46) months, respectively.
The combination of PLD and continuous IFO is a feasible and efficient treatment in patients with relapsed ovarian cancer, especially with TFI between 6 and 12 months. This regimen may represent an alternative to platinum reintroduction and should be evaluated in a randomized trial.

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The effect of ifosfamide and its metabolites on intracellular glutathione levels in vitro and in vivo

Abstract

Biochem Pharmacol

J Pharm Sci

Adv Cancer Res

J Biochem Biophys Meth

Methods Enzymol

Lancet

Cancer Treat Rev

Cancer Treat Rev

Experimental and clinical activity of ifosfamide and cyclophosphamide

Cancer Chemother Pharmacol

Studies on the metabolism of isophosphamide (NSC-109724) in Man

Cancer Treatment Rep