Correlation Of Cytochrome P450 Gene Polymorphisms With Plasma Concentrations And Adverse Reactions Of Anlotinib In Lung Cancer Patients

Lung cancer is one of the most frequent cancers,killing approximately 1.8 million people worldwide each year.In addition to traditional drugs,new cytotoxic drugs,molecular targeted therapies and immune checkpoint inhibitors have provided new ideas for cancer treatment.Among them,molecular targeted therapies have high specificity for tumor cells and low toxicity,which is considered as an ideal cancer treatment.Anlotinib is a small molecule multi-target tyrosine kinase inhibitor developed by China,which can effectively inhibit tumor angiogenesis and anti-tumor growth.Currently,anlotinib has shown significant efficacy in several cancers.Among them,the results of phase II and III studies in non-small cell lung cancer have shown that anlotinib can bring benefits in both overall survival（OS）and progression-free survival（PFS）in third-line treatment.As a result,anlotinib has been officially approved as a single agent for thirdline treatment in patients with advanced NSCLC in China.Due to the widespread use of anlotinib,there is widespread concern about its efficacy and safety.It has been reported that anlotinib is mainly metabolized by the hepatic cytochrome P450（CYP450）enzyme system,with CYP3A4 and CYP3A5 being the most readily metabolized.In vivo animal study discovered that anlotinib had a strong induction effect on CYP2D1 and CYP3A1/2.It has been shown that the adverse reactions of oncology drugs correlate with drug concentrations and metabolic enzyme gene polymorphisms.Metabolic enzyme gene polymorphisms can influence the systemic and local concentrations of drugs,as well as the occurrence of side effects,leading to individual differences.Although the study of vitro and vivo animal have confirmed the effect of CYP450 enzyme on the metabolism of anlotinib.However,the correlation between patients’ CYP450 gene polymorphisms and clinical adverse reactions and plasma drug concentrations remains unclear.This is the main focus of this study.Objective:The correlation between single nucleotide polymorphisms of CYP450 enzymes CYP2C19,CYP1A2,CYP3A4,CYP2C9 and CYP3A5 and plasma drug concentrations and adverse reactions in lung cancer patients treated with anlotinib may provide a basis for individualized treatment planning.Methods:Patients with lung cancer who were admitted to the First Affiliated Hospital of Anhui Medical University from January 2020 to August 2021 and administered orally anlotinib for more than 2 courses were collected.Basic information,Imaging data and adverse reactions information of the patients were recorded,and blood samples were collected.1.To develop an ultra-performance liquid chromatography-tandem mass spectrometry（UPLC-MS/MS）method for the determination of plasma anlotinib concentration in lung cancer patients and conduct methodological verification2.The genotype of CYP3A4（rs2242480,rs35599367,rs4646437,rs3735451,rs4646460）,CYP3A5（rs1419745,rs4646450,rs15524,rs3800959）,CYP2C19（rs11568732,rs12248560,rs12769205,rs3814637,rs4244285,rs4986893）,CYP1A2（rs2069526,rs2470890,rs4646425,rs4646427）and CYP2C9 rs9332113 in patients was detected by Mass ARRAY technique.3.SPSS statistical analysis software was used to analyze the correlation between CYP450 gene polymorphisms and anlotinib blood concentrations and adverse reactions.Results:1.The methodological verification of anlotinib concentration detection meets the requirements and can be used for the concentration detection of clinical samples of anlotinib.2.Seventy-three of 139 lung cancer patients received 8 mg anlotinib per day,and 66 patients received 12 mg anlotinib per day.The trough concentrations min（Cmin-d22）and trough concentrations max（Cmax-d15）concentrations in lung cancer patients treated with anlotinib（8 mg）were 17.59 ± 12.55 ng/mL and 27.01 ± 7.97 ng/mL,respectively.On the other hand,Cmin-d22and Cmax-d15 after anlotinib（12 mg）dosing were 23.51 ± 14.83 ng/mL and 41.22 ± 27.15 ng/mL,respectively.This indicates that plasma drug concentrations of anlotinib in patients vary greatly among individuals.3.The distribution of adverse reactions among 139 patients was as follows:hypertension（21.6%）,hemoptysis（8.6%）,elevated thyroid stimulating hormone（11.5%）,hepatotoxicity（8.6%）,hypertriglyceridemia（16.5%）,hand-foot syndrome（10.8%）,Proteinuria（20.8%）,Weakness（10.1%）,Dyspepsia（11.5%）,Hoarse（5.8%）,Diarrhea（5.8%）,Dizziness（9.5%）,Nausea（2.2%）and Rash（14.4%）.4.When the plasma Cmin-d22 of anlotinib in patients was≥47.75ng/mL,the incidence of severe hypertension was significantly higher than that of patients with Cmind22<47.75ng/mL.When the plasma Cmin-d22≥29.07ng/mL of anlotinib in patients,the incidence of severe hepatotoxicity was significantly higher than that in patients with Cmin-d22<29.07ng/mL.5.The HWE test was performed on the genotyping results of 20 loci in 139 lung cancer patients.The results showed that the CYP3 A4-rs35599367 genotype was not mutated（P<0.05）and did not conform to HWE.The SNP frequencies of the remaining 19 loci were not significantly different from the expected frequencies and were consistent with HWE（P>0.05）.This indicates that the sample in this study is representative in general.6.For CYP2C19-rs3814637,the Cmax-d 15 mutant allele T carriers（TT+CT）were significantly higher than that in wild-types（CC）.For CYP2C19-rs11568732,the Cmax-d15 mutant allele G carriers（GT+GG）were significantly higher than that in wild-types（TT）.In addition,the incidence rate of Hypertension in mutate allele T carriers（CT+TT）in rs3814637 was significantly higher than that in wild-types（CC）（P=0.034）.The incidence rate of Hypertension in mutate allele G carriers（GT+GG）in rs 11568732 was significantly higher than that in wild-types（TT）（P=0.034）.The incidence rate of hemoptysis（Peripheral lung cancer）in mutate allele G carriers（GT+GG）in rs11568732 was significantly higher than that in wild-types（TT）（P=0.043）.The incidence rate of hemoptysis（Peripheral lung cancer）in mutate allele T carriers（CT+TT）in rs3 814637 was significantly higher than that in wild-types（CC）（P=0.043）.There was no significant difference between rs11568732 and rs3814637 genotypes in the incidence of hemoptysis in central lung cancer（P>0.05）.The incidence rate of hepatotoxicity in C carriers（CT+CC）in CYP3A5-rs1419745 was significantly lower than that in wild-types（TT）（P=0.011）.The incidence rate of hepatotoxicity in mutant allele G carriers（GA+GG）in CYP3A5-rs 15524 was significantly lower than that in wild-types（AA）（P=0.031）.Conclusion:The polymorphisms of CYP2C19 were significantly associated with hypertension,hemoptysis,and as well as anlotinib Cmax-d15.The polymorphisms of CYP3A5 were significantly correlated with hepatotoxicity.The Cmin-d22 of anlotinib can be used as a predictive indicator of severe hypertension and severe hepatotoxicity.Polymorphisms in the CYP450 enzyme may explain the interindividual differences of anlotinib adverse reactions.