Capecitabine

Capecitabine, sold under the brand name Xeloda among others, is a anticancer medication used to treat breast cancer, gastric cancer and colorectal cancer.^[3] For breast cancer it is often used together with docetaxel.^[4] It is taken by mouth.^[4]

Capecitabine

Clinical data
Pronunciation	/kæpɪˈsaɪtəbiːn/
Trade names	Xeloda, Xitabin, Kapetral, others
AHFS/Drugs.com	Monograph
MedlinePlus	a699003
Pregnancy category	AU: D
Routes of administration	By mouth
Drug class	Antineoplastic agent
ATC code	L01BC06 (WHO)
Legal status
Legal status	AU: S4 (Prescription only) CA: ℞-only UK: POM (Prescription only) US: WARNING[1]Rx-only EU: Rx-only[2]
Pharmacokinetic data
Bioavailability	Extensive
Protein binding	< 60%
Metabolism	liver, to 5'-DFCR, 5'-DFUR (inactive); neoplastic tissue, 5'-DFUR to active fluorouracil
Elimination half-life	38–45 minutes
Excretion	kidney (95.5%), faecal (2.6%)
Identifiers
IUPAC name Pentyl [1-(3,4-dihydroxy-5-methyltetrahydrofuran-2-yl)-5-fluoro-2-oxo-1H-pyrimidin-4-yl]carbamate
CAS Number	154361-50-9 Y
PubChem CID	60953
IUPHAR/BPS	6799
DrugBank	DB01101 Y
ChemSpider	54916 Y
UNII	6804DJ8Z9U
KEGG	D01223 Y
ChEBI	CHEBI:31348 Y
ChEMBL	ChEMBL1773 Y
CompTox Dashboard (EPA)	DTXSID3046451
ECHA InfoCard	100.112.980
Chemical and physical data
Formula	C15H22FN3O6
Molar mass	359.354 g·mol−1
3D model (JSmol)	Interactive image
SMILES FC=1\C(=N/C(=O)N(C=1)[C@@H]2O[C@@H]([C@@H](O)[C@H]2O)C)\NC(=O)OCCCCC
InChI InChI=1S/C15H22FN3O6/c1-3-4-5-6-24-15(23)18-12-9(16)7-19(14(22)17-12)13-11(21)10(20)8(2)25-13/h7-8,10-11,13,20-21H,3-6H2,1-2H3,(H,17,18,22,23)/t8-,10-,11-,13-/m1/s1 Y Key:GAGWJHPBXLXJQN-UORFTKCHSA-N Y
(verify)

Common side effects include abdominal pain, vomiting, diarrhea, weakness, and rashes.^[4] Other severe side effects include blood clotting problems, allergic reactions, heart problems such as cardiomyopathy, and low blood cell counts.^[4] Use during pregnancy may result in harm to the fetus.^[4] Capecitabine, inside the body, is converted to 5-fluorouracil (5-FU) through which it acts.^[4] It belongs to the class of medications known as fluoropyrimidines, which also includes 5-FU and tegafur.^[5]

Capecitabine was patented in 1992 and approved for medical use in 1998.^[6] It is on the World Health Organization's List of Essential Medicines.^[7]

Medical uses

Capecitabine is indicated for

• adjuvant treatment of people with Stage III colon cancer as a single agent or as a component of a combination chemotherapy regimen;^[8]
• perioperative treatment of adults with locally advanced rectal cancer as a component of chemoradiotherapy;^[8]
• treatment of people with unresectable or metastatic colorectal cancer as a single agent or as a component of a combination chemotherapy regimen;^[8]
• treatment of people with advanced or metastatic breast cancer as a single agent if an anthracycline- or taxane-containing chemotherapy is not indicated;^[8]
• treatment of people with advanced or metastatic breast cancer in combination with docetaxel after disease progression on prior anthracycline-containing chemotherapy;^[8]
• treatment of adults with unresectable or metastatic gastric, esophageal, or gastroesophageal junction cancer as a component of a combination chemotherapy regimen;^[8]
• treatment of adults with HER2-overexpressing metastatic gastric or gastroesophageal junction adenocarcinoma who have not received prior treatment for metastatic disease as a component of a combination regimen;^[8]
• adjuvant treatment of adults with pancreatic adenocarcinoma as a component of a combination chemotherapy regimen.^[8]

Adverse effects

Adverse effects by frequency:^{[9][10][11][12]}

Very common (>10% frequency)

• Appetite loss
• Diarrhea
• Vomiting
• Nausea
• Stomatitis
• Abdominal pain
• Fatigue
• Weakness
• Hand-foot syndrome^[13]
• Oedema
• Fever
• Pain
• Headache
• Hair loss
• Dermatitis
• Indigestion
• Shortness of breath
• Eye irritation
• Myelosuppression^{[Note 1]}

Notes on adverse effects:

1. Includes: anaemia, lymphopenia, neutropenia and thrombocytopenia

Contraindications

Contraindications include:^[11]

• History of hypersensitivity to fluorouracil, capecitabine or any of its excipients
• DPD deficiency (see Pharmacogenetics)
• Pregnancy and lactation
• Severe leucopenia, neutropenia, or thrombocytopenia
• Severe hepatic impairment or severe renal impairment
• Treatment with sorivudine or its chemically related analogues, such as brivudine

In 2020, the EU and UK license was updated to state that capecitabine was contra-indicated in patients that "have a known complete absence of dihydropyrimidine dehydrogenase (DPD) activity".^[14] In US, as of 2024, there is no specific contraindication on the package inserts however, there is a cautionary warning: "Patients with certain homozygous or compound heterozygous variants in the DPYD gene are at increased risk for acute early-onset toxicity and serious, including fatal, adverse reactions due to XELODA (e.g., mucositis, diarrhea, neutropenia, and neurotoxicity). XELODA is not recommended for use in patients known to have certain homozygous or compound heterozygous DPYD variants that result in complete absence of DPD activity. Withhold or permanently discontinue based on clinical assessment. No XELODA dose has been proven safe in patients with complete absence of DPD activity. "^[15]

Within the UK, DPYD testing to check for this contraindication is now routine practice,^[16] this is not the case in the US.^[17]

Drug interactions

Drugs it is known to interact with include:^[11]

• Sorivudine or its analogues, such as, brivudine.
• CYP2C9 substrates, including, warfarin and other coumarin-derivatives anticoagulants
• Phenytoin, as it increases the plasma concentrations of phenytoin.
• Calcium folinate may enhance the therapeutic effects of capecitabine by means of synergising with its metabolite, 5-FU. It may also induce more severe diarrhoea by means of this synergy.^[18]

Pharmacogenetics

The dihydropyrimidine dehydrogenase (DPD) enzyme is responsible for the detoxifying metabolism of fluoropyrimidines, a class of drugs that includes capecitabine, 5-fluorouracil and tegafur.^[5] Genetic variations within the DPD gene (DPYD) can lead to reduced or absent DPD activity, and individuals who are heterozygous or homozygous for these variations may have partial or complete DPD deficiency; an estimated 0.2% of individuals have complete DPD deficiency.^[5][19] Those with partial or complete DPD deficiency have a significantly increased risk of severe or even fatal drug toxicities when treated with fluoropyrimidines; examples of toxicities include myelosuppression, neurotoxicity and hand-foot syndrome.^[5][19]

Mechanism of action

Click on genes, proteins and metabolites below to link to respective articles.^{[§ 1]}

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|alt=Fluorouracil (5-FU) Activity edit]]

Fluorouracil (5-FU) Activity edit

1. The interactive pathway map can be edited at WikiPathways: "FluoropyrimidineActivity_WP1601".

Capecitabine is metabolised to 5-FU which in turn is a thymidylate synthase inhibitor, hence inhibiting the synthesis of thymidine monophosphate (ThMP), the active form of thymidine which is required for the de novo synthesis of DNA.^[20]

Drug synthesis

Overdose

Uridine Triacetate is a potential antidote for cases of suspected overdose.^[21]

Society and culture

Brand names

One of the brand names is Xeloda, marketed by Genentech.

Others include Xitabin, Capcibin, Kapetral and Pecaset by Eurolab.

References

1. "FDA-sourced list of all drugs with black box warnings (Use Download Full Results and View Query links.)". nctr-crs.fda.gov. FDA. Retrieved 22 October 2023.
2. "Xeloda EPAR". European Medicines Agency. 2 February 2001. Retrieved 2 July 2024.
3. British national formulary : BNF 69 (69 ed.). British Medical Association. 2015. pp. 585, 588. ISBN 9780857111562.
4. "Capecitabine". The American Society of Health-System Pharmacists. Archived from the original on 15 April 2016. Retrieved 8 December 2016.
5. Caudle KE, Thorn CF, Klein TE, Swen JJ, McLeod HL, Diasio RB, et al. (December 2013). "Clinical Pharmacogenetics Implementation Consortium guidelines for dihydropyrimidine dehydrogenase genotype and fluoropyrimidine dosing". Clinical Pharmacology and Therapeutics. 94 (6): 640–645. doi:10.1038/clpt.2013.172. PMC 3831181. PMID 23988873.
6. Fischer J, Ganellin CR (2006). Analogue-based Drug Discovery. John Wiley & Sons. p. 511. ISBN 9783527607495. Archived from the original on 12 January 2023. Retrieved 30 August 2017.
7. World Health Organization (2019). World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. hdl:10665/325771. WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO.
8. "FDA approves updated drug labeling including new indications and dosing regimens for capecitabine tablets under Project Renewal". U.S. Food and Drug Administration. 15 December 2022. Archived from the original on 27 January 2023. Retrieved 26 January 2023. This article incorporates text from this source, which is in the public domain.
9. "XELODA (capecitabine) tablet, film coated [Genentech, Inc.]". DailyMed. Genentech, Inc. December 2013. Archived from the original on 1 February 2014. Retrieved 25 January 2014.
10. "Capecitabine Teva : EPAR – Product Information" (PDF). European Medicines Agency. Teva Pharma B.V. 10 January 2014. Archived (PDF) from the original on 4 February 2014. Retrieved 25 January 2014.
11. "Capecitabine 150mg – Summary of Product Characteristics (SPC)". electronic Medicines Compendium. Zentiva. 23 December 2013. Archived from the original on 1 February 2014. Retrieved 25 January 2014.
12. "NAME OF THE MEDICINE XELODA® Capecitabine" (PDF). TGA eBusiness Services. Roche Products Pty Limited. 5 December 2013. Archived from the original on 11 September 2017. Retrieved 25 January 2014.
13. Reddening, swelling, numbness and desquamation on palms and soles
14. ATC code (23 April 2021). "Summary of Product Characteristics (SmPC)". (emc). Retrieved 5 January 2025.
15. "FDA approves updated drug labeling including new indications". U.S. Food and Drug Administration. 1 October 2024. Retrieved 5 January 2025.
16. Robinson J (5 May 2022). "Cancer pharmacogenomics testing: are we hitting the mark?". The Pharmaceutical Journal. Retrieved 26 December 2024.
17. Koo K, Pasternak AL, Henry NL, Sahai V, Hertz DL (June 2022). "Survey of US Medical Oncologists' Practices and Beliefs Regarding DPYD Testing Before Fluoropyrimidine Chemotherapy". JCO Oncology Practice. 18 (6): e958 – e965. doi:10.1200/OP.21.00874. PMC 9191302. PMID 35239419.
18. Rossi S, ed. (2013). Australian Medicines Handbook (2013 ed.). Adelaide: The Australian Medicines Handbook Unit Trust. ISBN 978-0-9805790-9-3.
19. Amstutz U, Froehlich TK, Largiadèr CR (September 2011). "Dihydropyrimidine dehydrogenase gene as a major predictor of severe 5-fluorouracil toxicity". Pharmacogenomics. 12 (9): 1321–1336. doi:10.2217/pgs.11.72. PMID 21919607.
20. "Xeloda (capecitabine) dosing, indications, interactions, adverse effects, and more". Medscape Reference. WebMD. 25 January 2014. Archived from the original on 2 February 2014.
21. Ma WW, Saif WM, Cartwright TH, Fakih M, El-Rayes BF, King T, et al. (20 May 2016). "Uridine triacetate as a lifesaving antidote for overdoses and severe early-onset 5-fluorouracil and capecitabine toxicities". Journal of Clinical Oncology. 34 (15_suppl): e21689 – e21689. doi:10.1200/JCO.2016.34.15_suppl.e21689. ISSN 0732-183X.

Further reading

• Dean L (2016). "Capecitabine Therapy and DPYD Genotype". In Pratt VM, McLeod HL, Rubinstein WS, et al. (eds.). Medical Genetics Summaries. National Center for Biotechnology Information (NCBI). PMID 28520372. Bookshelf ID: NBK385155.