Fluorouracil – Use, Dosage, Side Effects, Interaction

Fluorouracil is an antimetabolite fluoropyrimidine analog of the nucleoside pyrimidine with antineoplastic activity. Fluorouracil and its metabolites possess a number of different mechanisms of action. In vivo, fluorouracil is converted to the active metabolite 5-fluoroxyuridine monophosphate (F-UMP); replacing uracil, F-UMP incorporates into RNA and inhibits RNA processing, thereby inhibiting cell growth. Another active metabolite, 5-5-fluoro-2′-deoxyuridine-5′-O-monophosphate (F-dUMP), inhibits thymidylate synthase, resulting in the depletion of thymidine triphosphate (TTP), one of the four nucleotide triphosphates used in the in vivo synthesis of DNA. Other fluorouracil metabolites incorporate into both RNA and DNA; incorporation into RNA results in major effects on both RNA processing and functions.

Mechanism of Action

The precise mechanism of action has not been fully determined, but the main mechanism of fluorouracil is thought to be the binding of the deoxyribonucleotide of the drug (FdUMP) and the folate cofactor, N5–10-methylenetetrahydrofolate, to thymidylate synthase (TS) to form a covalently bound ternary complex. This results in the inhibition of the formation of thymidylate from uracil, which leads to the inhibition of DNA and RNA synthesis and cell death. Fluorouracil can also be incorporated into RNA in place of uridine triphosphate (UTP), producing a fraudulent RNA and interfering with RNA processing and protein synthesis.

or

5-FU requires enzymatic conversion to the nucleotide (ribosylation and phosphorylation) in order to exert its cytotoxic activity. Several routes are available for the formation of the 5′-monophosphate nucleotide (F-UMP) in animal cells. 5-FU may be converted to fluorouridine by uridine phosphorylase and then to F-UMP by uridine kinase, or it may react directly with 5-phosphoribosyl-1-pyrophosphate (PRPP), in a reaction catalyzed by orotate phosphoribosyl transferase, to form F-UMP. Many metabolic pathways are available to F-UMP, including incorporation into RNA. A reaction sequence crucial for antineoplastic activity involves the reduction of the diphosphate nucleotide by the enzyme ribonucleoside diphosphate reductase to the deoxynucleotide level and the eventual formation of 5-fluoro-2′-deoxyuridine-5′-phosphate (F-dUMP). 5-FU also may be converted directly to the deoxyriboside 5-FUdR by the enzyme thymidine phosphorylase and further to F-dUMP, a potent inhibitor of thymidylate synthesis, by thymidine kinase … The interaction between F-dUMP and the enzyme thymidylate synthase leads to the depletion of TTP, a necessary constituent of DNA … The folate cofactor, 5,10-methylenetetrahydrofolate, and F-dUMP form a covalently bound ternary complex with the enzyme. The inhibitory complex resembles the transition state formed during the normal enzymatic reaction when dUMP is converted to thymidylate. Although the physiological complex progresses to the synthesis of thymidylate by transfer of the methylene group and 2 hydrogen atoms from folate to dUMP, this reaction is blocked in the inhibitory complex by the stability of the fluorine carbon bond on F-dUMP; sustained inhibition of the enzyme results

Fluorouracil is an antineoplastic anti-metabolite. Anti-metabolites masquerade as purine or pyrimidine – which become the building blocks of DNA. They prevent these substances from becoming incorporated into DNA during the “S” phase (of the cell cycle), stopping normal development and division. Fluorouracil blocks an enzyme that converts the cytosine nucleotide into the deoxy derivative. In addition, DNA synthesis is further inhibited because Fluorouracil blocks the incorporation of the thymidine nucleotide into the DNA strand.

Indications

  • For the topical treatment of multiple actinic or solar keratoses. In the 5% strength, it is also useful in the treatment of superficial basal cell carcinomas when conventional methods are impractical, such as with multiple lesions or difficult treatment sites. Fluorouracil injection is indicated in the palliative management of some types of cancer, including colon, esophageal, gastric, rectum, breast, biliary tract, stomach, head and neck, cervical, pancreas, renal cell, and carcinoid.
  • Fluorouracil (5-FU) is a pyrimidine analog used as an antineoplastic agent to treat multiple solid tumors including colon, rectal, breast, gastric, pancreatic, ovarian, bladder, and liver cancer.
  • Antimetabolites; Antimetabolites, Antineoplastic; Immunosuppressive Agents
  • Fluorouracil is indicated for the palliative treatment of carcinoma of the colon, rectum, breast, stomach, and pancreas in patients considered to be incurable by surgery or other means.
  • Fluorouracil is also indicated for the treatment of bladder carcinoma, prostatic carcinoma, epithelial ovarian carcinoma, cervical carcinoma, endometrial carcinoma, anal carcinoma, esophageal carcinoma, metastatic tumors of skin carcinoma, hepatoblastoma, and is used by intra-arterial injection for the treatment of hepatic tumors and head and neck tumors.
  • Actinic Keratosis (AK)
  • Breast Cancer
  • Malignant Neoplasm of Colon
  • Malignant Neoplasm of Pancreas
  • Malignant Neoplasm of Stomach
  • Rectal Carcinoma
  • Superficial Basal Cell Carcinoma
  • Verruca (Warts)
  • Hyperkeratotic actinic keratosis

Use in Cancer

Fluorouracil injection is approved to treat:

Fluorouracil is also called 5-FU. Fluorouracil is also being studied in the treatment of other conditions and types of cancer.

Fluorouracil is also available in a topical form. For more information, see the Drug Information Summary for Fluorouracil (Topical).

Contra-Indications

  • Hypersensitivity to the active component or any of the ingredients
  • Pregnancy
  • In patients with dihydropyrimidine dehydrogenase (DPD) enzyme deficiency
  • caloric undernutrition
  • decreased function of bone marrow
  • decreased blood platelets
  • a significant decrease in certain blood clotting cells called platelets
  • low levels of white blood cells
  • low levels of a type of white blood cell called neutrophils
  • angina, a type of chest pain
  • abnormal EKG with QT changes from birth
  • bleeding
  • throat irritation
  • stomatitis, a condition with painful swelling and sores inside the mouth
  • stomach or intestinal ulcer
  • liver problems
  • bleeding of the stomach or intestines
  • decreased kidney function
  • erythrodysesthesia or tingling, pain, redness, and edema in the hands and feet
  • excessive vomiting
  • diarrhea
  • pregnancy
  • a patient who is producing milk and breastfeeding
  • dihydropyrimidine dehydrogenase deficiency
  • spread of malignant cancer to the bone marrow

Dosage

Strengths: 5%; 2%; 1%; 0.5%; 4%

Keratosis

  • 0.5% cream (microsphere formulation): Apply to the affected area once a day where actinic keratosis lesions appear, using enough to cover the entire area with a thin film
  • Duration of therapy: Apply for up to 4 weeks as tolerated; continued treatment up to 4 weeks results in greater lesion reduction; local irritation is not markedly increased by extending treatment from 2 to 4 weeks, and is generally resolved within 2 weeks of cessation of therapy 1%, 2%, 5% cream or 2%, 5% solution: Apply 2 times a day in an amount enough to cover the lesions; continue until the inflammatory response reaches the erosion stage, then discontinue use
  • Duration of therapy: 2 to 4 weeks; complete healing of the lesions may not be evident for 1 to 2 months following cessation of therapy
  • The response starts with erythema, usually followed by vesiculation, desquamation, erosion and re-epithelialization.
  • This drug should not be applied near the eyes, nostrils, or mouth.
  • Apply 10 minutes after washing, rinsing, and drying the entire area.
  • This drug may be applied using the fingertips.
  • Immediately after application, the hands should be thoroughly washed.
  • Solar keratoses which do not respond to treatment should be biopsied to confirm the diagnosis.

Basal Cell Carcinoma

  • 5% cream or solution:
  • Apply 2 times a day in an amount sufficient to cover the lesions; continue until the inflammatory response reaches the erosion stage, then discontinue use
  • Duration of therapy: 3 to 6 weeks; however, therapy may be required for as long as 10 to 12 weeks before lesions are obliterated
  • Only a 5% cream or solution is recommended to treat superficial basal cell carcinoma.
  • The response starts with erythema, usually followed by vesiculation, desquamation, erosion and re-epithelialization.

Administration advice:

  • Apply with a nonmetal applicator or glove; if applied with the fingers, the hands should be washed immediately afterward.
  • Avoid contact with mucous membranes, eyelids, eyes, nostrils, or mouth.
  • Avoid prolonged exposure to ultraviolet light or sunlight.
  • Avoid occlusive dressings unless clinically indicated.

General:

  • Deep, penetrating, or nodular basal cell and squamous cell carcinomas do not usually respond to this drug; it should be used only as a palliative therapy in such cases where no other form of treatment is possible.
  • The 0.5%, 1%, and 2% strengths should not be used in the treatment of basal cell carcinoma.
  • When this drug is applied to a lesion, a response occurs with the following sequence: erythema, usually followed by vesiculation, desquamation, erosion, and reepithelialization

Side Effects

The Most Common

  • burning, crusting, redness,
  • discoloration, irritation, pain,
  • itching, rash, or
  • soreness at the site of application
  • severe stomach pain
  • bloody diarrhea
  • vomiting
  • fever
  • chills
  • severe red skin rash
  • Local pain
  • Itchiness
  • Burning
  • Stinging
  • Crusting
  • Weeping
  • Dermatitis
  • Photosensitivity

More Common

  • Nausea
  • Vomiting
  • Diarrhea (see below for details)
  • Mucositis
  • Headache
  • Myelosuppression (see below for details)
  • Alopecia (hair loss)
  • Photosensitivity
  • Hand-foot syndrome
  • Maculopapular eruption
  • Itch
  • Cardiotoxicity (see below for details)
  • Persistent hiccups
  • Mood disorders (irritability, anxiety, depression)
  • skin pain, itching, burning, or irritation;
  • skin darkening or scarring;
  • skin redness and swelling; or
  • small blood vessels under the skin.

Rare

  • Oesophagitis
  • GI ulceration and bleeding
  • Proctitis
  • Nail disorders
  • Vein pigmentation
  • Confusion
  • Cerebellar syndrome
  • Encephalopathy
  • Visual changes
  • Photophobia
  • Lacrimation (the expulsion of tears without any emotional or physiologic reason)
  • Anaphylaxis
  • Allergic reactions
  • Fever without signs of infection

Drug Interaction

Pregnancy and lactation

AU TGA pregnancy category: D
US FDA pregnancy category: Not assigned.

Pregnancy

This drug can harm a developing fetus when administered to a pregnant woman. No adequate and well-controlled studies have been conducted in pregnant women with either topical or parenteral forms. One birth defect (ventricular septal defect) and cases of miscarriage have been reported when this drug was applied to mucous membrane areas. Multiple birth defects have been reported in the fetus of a patient treated with the IV formulation.

Lactation

Most sources consider breastfeeding to be contraindicated during maternal antineoplastic drug therapy. It might be possible to breastfeed safely during intermittent therapy with an appropriate period of breastfeeding abstinence, but the duration of abstinence is not clear.

How should this medicine be used?

Fluorouracil comes as a solution and a cream to apply to the skin. It is usually applied to the affected areas twice a day. To help you remember to use fluorouracil, apply it around the same times every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Use fluorouracil exactly as directed. Do not apply more or less of it or apply it more often than prescribed by your doctor.

If you are using fluorouracil to treat actinic or solar keratoses, you should continue using it until the lesions start to peel off. This usually takes about 2 to 4 weeks. However, the lesions may not be completely healed until 1 or 2 months after you stop using fluorouracil.

If you are using fluorouracil to treat basal cell carcinoma, you should continue using it until the lesions are gone. This usually takes at least 3 to 6 weeks, but may take as long as 10 to 12 weeks.

During the first few weeks of treatment, the skin lesions and surrounding areas will feel irritated and look red, swollen, and scaly. This is a sign that fluorouracil is working. Do not stop using fluorouracil unless your doctor has told you to do so.

Apply fluorouracil cream with a nonmetal applicator, a glove, or your finger. If you apply fluorouracil cream with your finger, be sure to wash your hands well immediately afterward. Do not cover the treated areas with a bandage or dressing unless your doctor tells you to.

Do not apply fluorouracil cream or topical solution to the eyelids or the eyes, nose, or mouth.

What special precautions should I follow?

Before using fluorouracil,

  • tell your doctor and pharmacist if you are allergic to fluorouracil or any other medications.
  • tell your doctor and pharmacist what prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking, especially other topical medications. Your doctor may need to change the doses of your medications or monitor you carefully for side effects.
  • tell your doctor if you have or have ever had dihydropyrimidine dehydrogenase (DPD) enzyme deficiency (a lack of a naturally occurring enzyme in your body).
  • tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while using fluorouracil , call your doctor immediately. Fluorouracil can harm the fetus.
  • plan to avoid unnecessary or prolonged exposure to sunlight and UV light (such as tanning booths) and to wear protective clothing, sunglasses, and sunscreen. Fluorouracil may make your skin sensitive to sunlight.

References

  1. https://pubchem.ncbi.nlm.nih.gov/compound/Fluorouracil
  2. https://www.drugs.com/mtm/fluorouracil-topical.html
  3. https://go.drugbank.com/drugs/DB00544
  4. https://en.wikipedia.org/wiki/Fluorouracil
  5. https://medlineplus.gov/druginfo/meds/a605010.html
  6. https://www.cancer.gov/about-cancer/treatment/drugs/fluorouracil
  7. CAMEO Chemical Reactivity Classification
  8. LICENSE
    The data from CAS Common Chemistry is provided under a CC-BY-NC 4.0 license, unless otherwise stated.
  9. Fluorouracil [USAN:USP:INN:BAN:JAN]
    ChemIDplus Chemical Information Classification
  10. 2,4(1H,3H)-Pyrimidinedione, 5-fluoro-
  11. CompTox Chemicals Dashboard Chemical Lists
  12. LICENSE
    The code for LOTUS is released under the GNU General Public License v3.0.
  13. NCI Thesaurus Tree
  14. LICENSE
    Data: CC-BY 4.0; Code (hosted by ECI, LCSB): Artistic-2.0
    5-Fluorouracil
    NORMAN Suspect List Exchange Classification
  15. LICENSE
    The content of the MoNA database is licensed under CC BY 4.0.
  16. 5-FLUORO-1H-PYRIMIDINE-2,4-DIONE
  17. IARC Classification
  18. PubChem
  19. LICENSE
    The Thieme Chemistry contribution within PubChem is provided under a CC-BY-NC-ND 4.0 license, unless otherwise stated.
  20. Antimetabolites, Antineoplastic
  21. Therapeutic category of drugs in Japan
    Anatomical Therapeutic Chemical (ATC) classification
    Target-based classification of drugs
    Drugs listed in the Japanese Pharmacopoeia
  22. NCBI

 

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