Pharmacokinetics of S-1, an oral formulation of ftorafur, oxonic acid and 5-chloro-2,4-dihydroxypyridine (molar ratio 1:0.4:1) in patients with solid tumors

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Abstract
S-1 is an oral formulation of ftorafur (FT), oxonic acid and 5-chloro-2,4-dihydroxypyridine (CDHP) at a molar ratio of 1:0.4:1. FT is a 5-fluorouracil (5-FU) prodrug, CDHP is a dihydropyrimidine dehydrogenase (DPD) inhibitor and oxonic acid is an inhibitor of 5-FU phosphoribosylation in the gastrointestinal mucosa and was included to prevent gastrointestinal toxicity. We determined the pharmacokinetics of S-1 in 28 patients at doses of 25, 35, 40 and 45 mg/m2. The plasma Cmax values of FT, 5-FU, oxonic acid and CDHP increased dose-dependently and after 1–2 h were in the ranges 5.8–13 μM, 0.4–2.4 μM, 0.026–1.337 μM, and 1.1–3.6 μM, respectively. Uracil levels, indicative of DPD inhibition, also increased dose-dependently from basal levels of 0.03–0.25 μM to 3.6–9.4 μM after 2–4 h, and 0.09–0.9 μM was still present after 24 h. The pharmacokinetics of CDHP and uracil were linear over the dose range. The areas under the plasma concentration curves (AUC) for CDHP and uracil were in the ranges 418–1735 and 2281–8627 μmol·min/l, respectively. The t1/2 values were in the ranges 213–692 and 216–354 min, respectively. Cumulative urinary excretion of FT was predominantly as 5-FU and was 2.2–11.9%; the urinary excretion of both fluoro-β-alanine and uracil was generally maximal between 6 and 18 h. During 28-day courses with twice-daily S-1 administration, 5-FU and uracil generally increased. Before each intake of S-1, 5-FU varied between 0.5 and 1 μM and uracil was in the micromolar range (up to 7 μM), indicating that effective DPD inhibition was maintained during the course. In a biopsy of an esophageal adenocarcinoma metastasis that had regressed, thymidylate synthase, the target of 5-FU, was inhibited 50%, but increased four- to tenfold after relapse in subsequent biopsies. In conclusion, oral S-1 administration resulted in prolonged exposure to micromolar 5-FU concentrations due to DPD inhibition, and the decrease in uracil levels after 6 h followed the pattern of CDHP and indicates reversible DPD inhibition.