Sunitinib for the treatment of metastatic gastrointestinal stromal tumors: the effect of TDM-guided dose optimization on clinical outcomes.

BACKGROUND: Sunitinib is an oral anticancer drug approved for the treatment of among others gastrointestinal stromal tumor (GIST). Previous analyses demonstrated an exposure-response relationship at the standard dose, and minimum target levels of drug exposure have been defined above which better treatment outcomes are observed. Therapeutic drug monitoring (TDM) could be used as a tool to optimize the individual dose, aiming at sunitinib trough concentrations ≥37.5 ng/ml for continuous dosing. Nonetheless, data on the added value of TDM-guided dosing on clinical endpoints are currently lacking. Therefore, we evaluate the effect of TDM in patients with advanced and metastatic GIST treated with sunitinib in terms of efficacy and toxicity. PATIENTS AND METHODS: A TDM-guided cohort was compared to a non-TDM-guided cohort in terms of median progression-free survival (mPFS) and overall survival (mOS). Also, mPFS between patients with and without dose-limiting toxicities (DLTs) was compared. Patients in the prospective cohort were included in two studies on TDM-guided dosing (the DPOG-TDM study and TUNE study). The retrospective cohort consisted of patients from the Dutch GIST Registry who did not receive TDM-guided dosing. RESULTS: In total, 51 and 106 patients were included in the TDM-guided cohort and non-TDM-guided cohort, respectively. No statistical difference in mPFS was observed between these two cohorts (39.4 versus 46.9 weeks, respectively; P = 0.52). Patients who experienced sunitinib-induced DLTs had longer mPFS compared to those who did not (51.9 versus 28.9 weeks, respectively; P = 0.002). CONCLUSIONS: Our results do not support the routine use of TDM-guided dose optimization of sunitinib in patients with advanced/metastatic GIST to improve survival.

Sequential triage in the first trimester may enhance advanced ultrasound scanning in population screening for trisomy 21.

OBJECTIVE: To design a trisomy 21 screening protocol for sequential triage in the first trimester, and to evaluate whether it reduces the need for advanced ultrasound scanning to such an extent that this could be dealt with by a limited number of well-trained sonographers only. METHODS: Screening results of 31 trisomy 21 affected pregnancies and 16 096 unaffected pregnancies from the first trimester screening program of Algemeen Medisch Laboratorium in Antwerp, Belgium, were used to define high-risk, intermediate-risk and low-risk groups. A serum screening result (age, pregnancy-associated plasma protein-A (PAPP-A) and free beta-human chorionic gonadotropin (beta-hCG)) of >or=1 : 30 and/or a nuchal translucency thickness (NT) measurement of >or= 3.5 mm were classified as high risk. A serum screening result of < 1 : 1000 together with an NT of < 3.5 mm were classified as low risk. Other results were considered intermediate risk, for which further advanced ultrasound screening would be indicated. This protocol was then evaluated prospectively in another population of 13 493 first-trimester pregnancies. RESULTS: Of the total population, 1.9% was identified as being high risk (14 trisomy 21 pregnancies and 222 unaffected pregnancies; prevalence, 1 : 17), 59.6% was identified as being low risk (three trisomy 21 pregnancies and 9615 unaffected pregnancies; prevalence, 1 : 3206) and 38.4% was identified as being intermediate risk (10 trisomy 21 pregnancies and 6190 unaffected pregnancies; prevalence, 1 : 620). A similar distribution was found in the prospective arm of the study. There was no reduction of overall screening performance compared with our current first-trimester combined screening program. The number of intermediate-risk pregnancies was sufficiently low as to enable advanced ultrasound scanning by well-trained sonographers only. CONCLUSION: In population screening for fetal trisomy 21, sequential triage in the first trimester can be achieved using very simple methods. Pregnancies at high or at low risk can be identified easily and the number of pregnancies at intermediate risk can be reduced sufficiently to enable advanced ultrasound scanning by well-trained sonographers only. A prospective study is needed to evaluate the performance of this approach and to compare its results with current combined or integrated screening algorithms.

Analysis of erythromycin and benzoylperoxide in topical gels by liquid chromatography.

Gels containing a combination of erythromycin and benzoylperoxide are frequently used in the treatment of acne vulgaris. A method was developed to determine the content of both erythromycin and benzoylperoxide in these gels. Erythromycin was extracted from the gel in conditions where the oxidative power of benzoylperoxide was neutralised by addition of ascorbic acid and this extract was analysed on an Xterra RP(18) column, with a mobile phase containing acetonitrile-0.2 M K2HPO4-water (35:5:60, v/v/v). The detection wavelength was 215 nm. A second extraction procedure was developed for the analysis of benzoylperoxide. The extraction solution was analysed on a Hypersil C(18) BDS column and a mobile phase containing acetonitrile-water (58:42, v/v). Detection was performed at 254 nm. The flow rate was 1.0 ml/min in both methods. The selectivity, repeatability, linearity and recovery of both methods were examined. Special attention was given to determination of the recovery and the uncertainty on the recovery. This allowed evaluation of the bias of the extraction method. The method developed was used to examine the stability of a gel for topical use.

Analysis of unknown compounds in azithromycin bulk samples with liquid chromatography coupled to ion trap mass spectrometry.

A selective reversed-phase liquid chromatography/mass spectrometry (LC/MS(n)) method is described for the identification of azithromycin impurities and related substances in commercial azithromycin samples. Mass spectral data are acquired on an LCQ ion trap mass spectrometer equipped with an atmospheric pressure chemical ionization interface operated in positive ion mode. The LCQ provides on-line LC/MS(n) capability, making it ideally suited for identification purposes. In comparison with UV detection, this hyphenated technique provides as its main advantage efficient identification of novel substances without time-consuming isolation and purification procedures. Using this technique, six novel related substances detected in commercial azithromycin samples have been studied.

Determination of kanamycin in serum by solid-phase extraction, pre-capillary derivatization and capillary electrophoresis.

An effective method based on solid-phase extraction (SPE) and capillary electrophoresis (CE) for the determination of kanamycin in human serum was developed and validated. Off-line SPE was employed for the isolation of kanamycin from serum on a carboxypropyl-bonded phase (CBA) weak cation-exchange cartridge. A mixture of 0.2 M borate (pH 10.5)-methanol (50:50, v/v) was used as analyte eluting solvent. After pre-capillary derivatization with o-phthalaldehyde/mercaptoacetic acid reagent, the sample was analyzed by CE with a separation buffer of 30 mM borax, pH 10.0, containing 16% (v/v) methanol. A linear response over the concentration range 5-40 microgram/ml was obtained with a detection limit of 2 microgram/ml. Intra-day and inter-day precision were 6.2 and 10.3% RSD, respectively. Recoveries of approximately 90% were found. For the determination of lower levels of kanamycin (<5 microgram/ml), NH(4)OH (25%, w/v)-methanol (30:70, v/v) was used for analyte elution. After evaporation, reconstitution and derivatization, the sample was analyzed by on-line field-amplified sample stacking (FASS) CE. Good linearity in the concentration range 0.4-5 microgram/ml was obtained with a detection limit of 0.1 microgram/ml. Intra-day and inter-day RSD were 3.4 and 11.2%, respectively. Recoveries of approximately 60% were found. The method was successfully applied to the analysis of kanamycin in sera of tuberculosis patients at peak level and trough level concentrations.

Isocratic liquid chromatographic method for the analysis of azithromycin and its structurally related substances in bulk samples.

An isocratic liquid chromatographic method with UV detection at 215 nm, which is suitable for the analysis of azithromycin (AZT) in bulk samples, is described. AZT is separated from its synthesis intermediates and a degradation product as well as from six unknown impurities on an XTerra RP18 column at 70 degrees C using a mobile phase consisting of acetonitrile-pH 6.5 0.2M K2HPO4-water (35:10:55, v/v/v) at 1.0 mL/min. The XTerra stationary phase contains methyl groups that are incorporated in the bulk structure of the material. This allows for special selectivities. Robustness is evaluated by a full factorial design experiment. The method shows good selectivity, repeatability, linearity, and sensitivity.

Analysis of spectinomycin by liquid chromatography with pulsed electrochemical detection.

Until now, no LC method is described to determine the purity and content of spectinomycin without prior derivatization. A reversed-phase ion-pair LC method using a base deactivated column and pulsed electrochemical detection is described. The mobile phase consisted of an aqueous solution containing 5.8 g/l pentafluoropropionic acid, 1.25 g/l potassium dihydrogen phosphate and 5.5 ml/l tetrahydrofuran. The pH was adjusted to 6.25 using dilute NaOH solution. An experimental design was used to optimize the chromatographic parameters and to check the robustness. The quality of separation was investigated on different stationary phases. The method allows the separation of spectinomycin from its related substances as well as some other components of unknown identity. The total time of analysis is 65 min. A number of commercial samples were examined using this method.

Study of the stability of polymyxins B(1), E(1) and E(2) in aqueous solution using liquid chromatography and mass spectrometry.

Polymyxins B(1), E(1) (colistin A) and E(2) (colistin B) were subjected to degradation in aqueous solutions of different pH values (1.4, 3.4, 5.4 and 7.4) and at different temperatures (37, 50 and 60 degrees C) in order to investigate the characteristics of decomposition. The progress of decomposition was followed by reversed-phase liquid chromatography on YMC-Pack Pro, C-18 stationary phase. The degradation curves showed (pseudo) first order kinetics. The pH-rate profiles indicate that colistin is more susceptible to degradation in solutions of pH above 5 and is more stable in acidic media. The degradation of polymyxin B(1) was most rapid at pH 7.4. Qualitative analysis of the degradation products by LC/MS reveals that racemization is the major mechanism of degradation in both acidic and neutral media.

Analysis of a formulation containing lincomycin and spectinomycin by liquid chromatography with pulsed electrochemical detection.

A reversed phase ion-pair liquid chromatographic method using a base deactivated column and pulsed electrochemical detection on a gold electrode is described. It allows the separation of a mixture of spectinomycin sulfate, lincomycin hydrochloride and their related substances. A step gradient was necessary to obtain a good separation together with a reasonable analysis time of 40 min. The mobile phases consisted of an aqueous solution of 3.3 or 0.55 g/l pentanesulfonic acid, 10 mM acetic acid and 20 ml/l tetrahydrofuran. Both mobile phases were adjusted to pH 4.0 with diluted sodium hydroxide. The influence of the different chromatographic parameters on the separation was investigated. Two commercial samples were analyzed using the described method. In total 12 components could be separated.

Analysis of clindamycin by micellar electrokinetic chromatography with a mixed micellar system.

This study details the development and validation of an optimized method with micellar electrokinetic chromatography for the analysis of clindamycin. The method uses a mixed micellar phase containing anionic sodium dodecylsulfate (SDS) and non ionic Brij 35 on an untreated fused-silica capillary. The influences of buffer concentration, pH, SDS, Brij 35 and organic modifier were investigated. Special attention was given to the role of the non ionic Brij 35 in the mixed micellar system. Optimization with a central composite design resulted in optimal separation conditions: background electrolyte containing 25 mM sodium tetraborate pH 7.75, 90 mM SDS, 14 mM Brij 35 and 21% acetonitrile. The applied voltage was 15 kV and the capillary temperature 15 degrees C. The method was robust and gave good linearity and repeatability. The limits of detection and quantitation were 0.05 and 0.15%, respectively, relative to a 2.5 mg/ml clindamycin solution. Two commercial bulk products were analysed with this system.

Electrophoretically mediated microanalysis of gentamicin with in-capillary derivatization and UV detection.

This paper describes a system for integration of a one-step-microscale chemical derivatization and analysis by a methodology known as electrophoretically mediated microanalysis (EMMA). Differential electrophoretic mobility between an analyte, reagent, and their product offers EMMA a unique capability to selectively carry out electrophoretic mixing, control product formation, and separation. This system was successfully applied to perform derivatization and separation of the multicomponent aminoglycoside antibiotic gentamicin using 1,2-phthalic dicarboxaldehyde and mercaptoacetic acid as labeling reagents. A multivariate approach based on central composite experimental design was used to optimize the derivative yield. Full automation of the derivatization and analytical procedure, high derivatization efficiency, high sample throughput, and precision are the excellent features of the present method. In addition, this methodology offers short analysis time, as well as selectivity and sensitivity suitable for impurities determination. Separation of gentamicin C1, C1a, C2, C2a, C2b, sisomicin, and several minor components was achieved. For the first time separation and identification of three impurities, namely garamine, 2-deoxystreptamine, and paromamine are described.

Isolation and structural characterization of colistin components.

Preparative-scale separation of colistin sulphate bulk sample was carried out on a preparative poly(styrene-divinylbenzene) stationary phase. Isocratic elution with acetonitrile-sodium sulphate solution (0.7% m/v; pH adjusted to 2.5 with TFA) - water (16:50:34, % v/v/v) was carried out at a flow rate of 4.0 ml min(-1). Six colistin components were isolated and characterized using 1H and 13C NMR. The molecular weights were confirmed by mass spectrometry. The structures of 2 components were determined for the first time. Polymyxin E7 was identified as having the same composition as polymyxin E1, except that the fatty acid moiety was 7-methyloctanoic acid. Isoleucine polymyxin E8 was characterized as having the same composition as isoleucine polymyxin E1 with 7-methylnonanoic acid as the fatty acid moiety.

Development and validation of a simple capillary zone electrophoresis method for the analysis of kanamycin sulfate with UV detection after pre-capillary derivatization.

Capillary zone electrophoresis was successfully applied to separate eight related substances of kanamycin and several minor unknowns from the main component. Strategies to enhance derivatization and selectivity and to optimize separation parameters involved the application of experimental designs. This chemometrical approach considers main effects as well as interactions of the influential parameters, thus conducting a more thorough investigation of the method than the common step-by-step approach. Central composite face centered designs established optimal separation conditions: 30 mM borax buffer, pH 10.0 containing 16.0% (v/v) methanol and optimal composition of derivatization reagent: 27 mg/ml 1,2-phthalic dicarboxaldehyde and 25 microl/ml mercaptoacetic acid in borate buffer, pH 10.4. The standard curves were linear over the concentration range of 0.007-1.01 mg/ml for the main component and 0.003-0.1 mg/ml for the related substances. The limit of quantitation was 0.14% (m/m) for the related substances and impurities (S/N= 10). The assay method was used to determine the composition of several commercial samples. Quantitative analysis indicates potential usefulness of capillary electrophoresis as an alternative to the assay method prescribed in the European Pharmacopoeia and the United States Pharmacopeia.

Analysis of vancomycin and related impurities by micellar electrokinetic capillary chromatography. Method development and validation.

A fast and highly selective micellar electrokinetic capillary chromatography (MEKC) method for quantitative analysis of vancomycin and related impurities is described. Among the tested surfactants, cetyltrimethylammonium chloride (CTAC) offered the best selectivity. Another important parameter, which strongly influenced the selectivity, was buffer pH. It was found that the selectivity increased with buffer pH decreasing from 9 to 5. Using Tris-phosphate buffer containing CTAC, satisfactory separation could be obtained in the pH range from 5.0 to 5.5. Excellent repeatability in terms of migration time and peak area could be obtained when the capillary was carefully washed between two runs. In order to obtain optimal conditions and to evaluate the method robustness, a central composite experimental design was carried out. The optimal conditions were: 44 cm length of fused-silica capillary with 50 microm ID, 120 mM Tris-phosphate buffer (pH 5.2) containing 50 mM CTAC, -15 kV applied voltage, UV detection at 210 nm, and a column temperature of 25 degrees C. Under the optimal conditions, more than 20 peaks could be separated within 8 min. The method has a linearity range from 0.004 to 1.2 mg/ml (concentration of vancomycin B, active component). The limit of detection (LOD) and limit of quantitation (LOQ) were 0.4 microg/mL vancomycin, equivalent to 0.3 microg/mL vancomycin B (0.04%) and 1.1 microg/mL vancomycin, equivalent to 0.9 microg/mL vancomycin B (0.1%), respectively.

Liquid chromatography of troleandomycin.

Until now no liquid chromatography (LC) method is described to determine the purity and content of troleandomycin and its related substances. A simple, robust, sensitive and selective isocratic liquid chromatographic method suitable for the determination of the antibiotic troleandomycin and its related substances is described. This method utilizes as a stationary phase: XTerra RP18 5 microm (25 cm x 4.6 mm I.D.) at 30 degrees C and as mobile phase: acetonitrile-0.2 M ammonium acetate buffer (pH 6.0)-water (45:5:50, v/v), delivered at a flow-rate of 1.0 ml/min. UV detection is performed at 205 nm. Troleandomycin is separated from the partially acetylated related substances and from several unknown impurities present in commercial samples. The robustness of the method was evaluated by a full-factorial experimental design.

Isolation and structural characterization of polymyxin B components.

Polymyxin B is a peptide antibiotic complex present as sulphate. The components were separated preparatively on a poly(styrene-divinylbenzene) (PLRP-S), 1000 A, 8 microm, 250 x 12.5 mm I.D. stationary phase maintained at 60 degrees C and using 215 nm detection. Elution was carried out with acetonitrile-sodium sulphate solution (0.7%, m/v; pH adjusted to 2.5 with trifluoroacetic acid)-water (18:50:32, v/v) at a flow-rate of 4.0 ml/min. Seven polymyxin B components were isolated and characterized using 1H and 13C NMR. The molecular masses were confirmed by mass spectrometry. The structures of two components were determined for the first time. Polymyxins B5 and B6 were identified as having the same composition as polymyxin B1 except that the fatty acid moiety was nonanoic acid and 3-hydroxy-6-methyloctanoic acid, respectively.

Analysis of bacitracin by micellar electrokinetic capillary chromatography with mixed micelle in acidic solution.

A method used for quantitative analysis of bacitracin with micellar electrokinetic capillary chromatography (MEKC) is described. As capillary zone electrophoresis gave poor separation selectivity, MEKC was preferable. It was found that a zwitterionic surfactant, 3-(N,N-dimethylhexadecylammonium)-propanesulfonate (PAPS) gave the best selectivity among the several surfactants studied. As the analytes tend to adsorb onto the capillary wall due to their positive charge, an acidic solution composed of Tris-phosphate buffer at pH 2.5 was necessary to diminish such adsorption. The peak tailing caused by relatively strong ion pair interaction between the analyte and PAPS micelle could be reduced by adding nonionic surfactant Brij 35 to the PAPS solution. This phenomenon is possibly explained by a mixed micelle mechanism. In order to obtain the optimal conditions and to test the method robustness, a central composite experimental design was performed. The optimal conditions are as follows: 44 cm length of fused-silica capillary with 50 microm inner diameter, 90 mM Tris-phosphate buffer (pH 2.5) containing 17 mM PAPS and 0.3% w/v-Brij 35, 18 kV applied voltage, UV detection at 192 nm and 25 degrees C column temperature. Under the optimal conditions, more than 50 peaks could be obtained in 30 min. The method had a linearity range from 1 to 0.05 mg/mL (concentration of bacitracin A). The limit of quantitation (LOQ) and limit of detection (LOD) were 0.005 and 0.0012 mg/mL, respectively.

Analysis of metacycline by capillary electrophoresis.

The development and validation of an optimized capillary electrophoresis method for the determination of metacycline in the presence of its related substances by capillary electrophoresis is shown. The influence of methanol as organic modifier, buffer pH, buffer concentration, capillary length, column temperature, Triton X-100 and methyl-beta-cyclodextrin was investigated. A central composite design was performed in order to optimize the method. The optimal separation conditions were: uncoated fused-silica capillary (39 cm total length, 31 cm effective length, 50 microm ID); as background electrolyte a solution of 160 mM sodium carbonate and 1 mM EDTA (pH 10.35)/methanol (89:13 v/v); temperature, 15 degrees C; voltage, 12 kV. The method showed good selectivity, repeatability, linearity, and sensitivity. The limits of detection and quantitation are 0.024% and 0.06%, respectively, relative to a 2.5 mg/mL solution. Six commercial samples were analyzed quantitatively.

Structure elucidation of four related substances in gramicidin with liquid chromatography/mass spectrometry.

A selective reversed phase liquid chromatography/mass spectrometry (LC/MS(n)) method is described for the identification of related substances in commercial gramicidin samples. Mass spectral data are acquired on an LCQ ion trap mass spectrometer equipped with an electrospray interface operated in the positive and the negative ion mode. The LCQ is ideally suited for identification of related substances because it provides on-line LC/MS(n) capability. Compared with UV detection the main advantage of this hyphenated LC/MS(n) technique is the efficient identification of novel related substances without time-consuming isolation and purification procedures. Using this method four novel related substances were separated and identified in a commercial sample.

Analysis of doxycycline by capillary electrophoresis. Method development and validation.

An optimized capillary electrophoresis method for the analysis of doxycycline is described. The influence of methanol as organic modifier, buffer pH, buffer concentration, capillary length, column temperature, Triton X-100 and methyl-beta-cyclodextrin was systematically investigated. A central composite design was performed in order to optimize the method. The optimal separation conditions were: capillary, uncoated fused-silica [40 cm (32 cm effective length) x 50 microm I.D.]; background electrolyte, a solution of 145 mM sodium carbonate and 1 mM EDTA brought to pH 10.3-methanol (89:11, v/v); temperature, 15 degrees C; voltage, 12 kV. The method showed good selectivity, repeatability, linearity and sensitivity. Six commercial samples were quantitatively analyzed. The results were compared with those established by the liquid chromatography method from the European Pharmacopoeia.