Biochemical Control of High-Dose Methotrexate/Leucovorin Rescue Therapy

Summary

High-dose methotrexate/Leucovorin rescue therapy is based on the assumption of differences in the transport system for folate compounds between normal and malignant proliferating cells. Thus, under normal conditions, methotrexate (MTX) and Leucovorin (citrovorum factor, CF) in low doses can enter the cells by an active transport system, whereas in some malignancies — such as osteosarcoma — these substances only penetrate through the cell membrane by passive diffusion if they are given in very high doses. Therefore, after high-dose MTX treatment, the cytotoxic effect of the folate antagonist is compensated for by rescue with Leucovorin in low doses only in the normal cell system. The consequence of this kind of treatment is a selective antitumor effect.

To avoid cytotoxic side effects, this therapeutic regimen must be monitored carefully. The decrease of the ratio of ³H-deoxyuridine (dUR)/³H-thymidine (dTR) incorporation into the DNA of the cells is a good biochemical parameter for estimating the MTX effect on rapidly proliferating cell systems. Using this indicator, it was shown that the usually administered dose of Leucovorin is not sufficient for an effective rescue of the bone marrow cells as long as the MTX serum concentration is equal or higher than 10^-6 M. If in critical cases the MTX elimination is retarded, a rescue can only be achieved by Leucovorin at doses tenfold higher than the actual amount of MTX in the whole body system. The Leucovorin rescue doses under such circumstances can be calculated according to the formula Leucovorin (mg) = 10 x MTX (mg/1) x 0.76 x body weight (kg).

This work was supported by the Deutsche Forschungsgemeinchaft. We thank Mrs. K. Heil, Mrs. R. Sarkar, Mrs. G. Stupp-Poutot, and Mrs. U. Wünsch for their skillful technical assistance