Cancer Chemothcr Pharmacol (1985) 14 : 274-276
`
`Short communication
`
`'-Cfllancer
`i
`,hemotherapy and
`Rharmacology
`© Springer—Verlag 1985
`
`A pharmacokinetic evaluation of IM administration
`of bleomycin oil suspension
`
`Margaret Davy ‘, Elisabeth Pans‘, Gustav Lehnez
`
`‘ The Norwegian Radium Hospital, Oslo, Norway
`3 H. Lundbeck Ltd., Oslo, Norway
`
`Summary. Bleomycin oil suspension was given IM twice daily to
`four patients, and bleomycin saline solution infused to three
`patients with cervical carcinoma. The serum levels of bleomycin
`were followed for l2 l1 by radioimmunocssay. Both regimens
`revealed comparable side effects‘. Only minor responses were
`seen. Bleornycin oil suspension produced prolonged levels of
`bleomycin in serum.
`
`Introduction
`
`The antitumor antibiotic bleomycin is effective in treating
`squamous cell carcinomas, malignant lymphomas and testicu-
`lar tumors. In 1976 Samuels et al.
`[11] showed a superior
`clinical response to conrinously infused bleomycin IV com-
`pared to conventional bolus administration in a non-random-
`ised study. This result was confirmed by animal studies
`showing that sustained plasma levels of bleomycin are related
`to enhanced inhibiton of tumor growth [9, 12]. Moreover, less
`toxic effects were seen with the continuous regimen [2]. Lung
`tissue especially was less vulnerable [5, 12]. It is essential to
`avoid exposing the pulmonary circulation to high levels of
`bleomycin as this exerts a direct toxic effect on the capillary
`endothelium.
`
`The rapid renal clearence of bleomycin demands a
`continuous infusion to maintain an adequate blood concen-
`tration. Pharrnacokinetic data obtained in rats, dogs, and
`rabbits show protracted elimination of bleomycin after IM
`administration of bleomycin oil suspension (B08), containing
`15 mg bleomycinlmi
`suspension in sesame oil with 1%
`alurniniurn monostearate as dispersing agent
`We have
`studied the depot properties of this BOS preparation in
`patients with advanced cervical carcinoma. The serum levels of
`bleomycin were measured by a radioimmunoassay utilizing
`radioiodinated bleomycin. No optimal
`therapeutic plasma
`level has been established, but a range of steady state
`concentrations of 10-150 nglml has been reported as thera-
`peutically effective [4, 6].
`
`Patients and methods
`
`Seven ambulatory patients with recurrent squamous cell
`carcinoma of the uterine cervix were studied. All had normal
`renal function. Four were treated with 0.3 ml BOS injections
`IM into the gluteal muscle twice daily (9 mg bleomycin) with a
`
`Ofrforinr requests for: G. Lehne, H. Lundbeck l.td., Box 188, 1324
`Lysaker, Norway
`
`4-h interval in order to mimic the sustained serunl levels
`
`achieved during infusion. Three received a standard regimen
`with 5 mg bleomycin in saline solution IV infused for 4 h. Both
`treatments lasted for 5 days. Blood was taken at hourly
`intervals, beginning just prior to the first bleomycin injection,
`and continuing for 12 h, on days 1 and 5 of therapy. Serum
`samples were stored at -20° C until analysis. Informed consent
`was obtained from all patients.
`
`Assay procedure and calculations. Determination of bleomycin
`in serum was performed with a conventional radioimmunoas-
`say essentially as described by Broughton and Strong [3].
`Bleoruycin obtained from H. Lundbeck Ltd., Copenhagen,
`was iodinated by the iodogen method [8]. The iodination of
`1 pg bleomycin with 0.2 mCi N317-5 I was performed in 0.5 molll
`sodium borate buffer pH 8.5, using 2 pg insolubilized iodogen
`as the oxidant. The reaction was allowed to proceed for 8 min
`at room temperature before separating free from bound
`radioactivity on a Sephadex G-10 column.
`Rabbit anti-bleomycin antiserum, purchased from Guild-
`hay Antisera, University of Surrey, was used at a dilution of
`1 : 4,800. All dilutions of reagents were made in assay buffer:
`0.01 molll phosphate buffer pH 7.0, containing 0.15 molll NaCl
`and 0.1% gelatin.
`The radioimmunoassay was performed by incubating 50 pl
`bleomycin
`standards
`(3-20!) nglrnl) or
`samples,
`100
`ul"*5I-bleomycin, 100 pl antiserum, and 350 pl assay buffer on
`ice for 3 h. Dextran coated charcoal, 200 pl, was added to
`Separate free from bound bleomycin. After 10 min at 0° C the
`tubes were centrifuged and decanted before counting.
`Bleomycin dilutions in serum were run as Controls at three
`different levels. The interassay coefficient of variation was in
`the range 8—12%,
`and the lower
`limit of detection
`3 nglml.
`The serum concentrations were graphed over time on
`semilog paper. The half-lives were calculated according to a
`one-compartment model, which gave the best fit for the
`elimination phase. This model was applied together with the
`trapezoidal method in analysis of the area under the curve,
`clearenec, and distribution volume. Comparisons were per-
`formed using van der Waerclen’s X-test.
`
`Results
`
`The bleomycin serum levels were slightly increased after the
`second BOS injection, and with one exception on the 5th day
`of B08 treatment (Fig. 1). The peak serum concentrations
`
`MYLAN PHARMS. INC. EXHIBIT 1052 PAGE 1
`
`MYLAN PHARMS. INC. EXHIBIT 1052 PAGE 1
`
`

`
`‘275
`
`AUC yield associated with BOS indicate delayed or incom-
`plete systernic uptake from the injection site. A second phase
`of retarded elimination was not found during the 12h of
`recording in our study, but have been demonstrated by others
`[13]. However, the delayed peak concentration, the prolonged
`serum half—life, the maintained therapeutically active concen-
`tration, and the huge distribution volume account for some
`depot effect of
`the BOS preparation.
`In contrast,
`IM
`adn-unistration of bleomyein saline solution is reported with
`peak levels obtained after one hour [7], a mean half-life of
`2.6 h [7], and no detectable levels in serum after 24 h
`[10, 13}.
`We have not been able to make a direct comparison
`between IM injections of BOS and bleomycin saline solution,
`because a 4-h infusion was used as control. In our department
`this was previously believed to be the most convenient way of
`maintaining serum levels within the therapeutic range in a
`prolonged periode of time. BOS seems even more convenient,
`and it does not demand hospitalization. Neither of the two
`schedules was able to show beneficial effect in these patients,
`but BOS may represent an advantage in treatment of tumors
`more responsive to bleomycin.
`
`Acknowledgements. The authors are grcatful to Felicity Reeve at
`Guildhay Antisera, University of Surrey, for the prompt supply of free
`samples of antisera. The authors thank Villy Hansen at H. Lundbcck
`Ltd. for competent assistance with the mathematical calculations.
`
`References
`
`1. Abe F, Tsuhosaki M, Tanaka T, Katoh Y, Yoshioka 0 (1976)
`Studies of absorption, excretion, and organ distribution of
`bleomycin oil suspension. Jpn J Antibiot 29: 826
`2. Baker LH (1918) A bleomycin combination for disseminated
`cervical cancer. In: Carter SK, Crooke ST, Umezawa H (eds)
`Bleornycin: Current status and new developments. Academic
`Press, New York, p 173
`3. Broughton A, Strong J E (1976) Radioimrnunoassay of bleomycin.
`Cancer Res 36: 1418
`
`4. Broughton A, Strong IE, Holoye FY, Bedrossian CW (1977)
`Clinical pharmacology of bleomycin following intravenous infu-
`sion as determined by radioirnmunoassay. Cancer 40: 2772
`5. Cooper KR, Hong WK (1981) Prospective study of the pulmonary
`toxicity of continuously infused blcornycin. Cancer Treat Rep
`65:419
`
`6. Ginsberg SJ, Crooke ST, Bloomfield CD, Peterson B, Kennedy
`13], Bloom J, Ellison RR, Pajak TF, Gottlieb AJ (1982)
`Cyclophosphamide, doxorubicin, vincristine, and low—dose con-
`tinuous infusion bleomycin in non-Hodgkin's lymphoma. Cancer
`49:1346
`
`7. Oken MM, Crooke ST, Elson MK, Strong IE, Shafer RB (1981)
`Pharmacokinetics of bleornycin after IM administration in man.
`Cancer Treat Rep 65: 485
`8. Paus E, Bormer O, Nustad K (1982) Radioiodination of proteins
`with the iodogen method.
`In:
`International Atomic Energy
`Agency (ed) Radioirnmunoassay and related procedures in
`medicine 1982. IAEA, Vienna. p 161
`9. Pong YM, Alherts os, Chen HS, Mason N, Moon TE (1930)
`Antitumour activity and plasma kinetics of bleornycin by contin-
`uous and intermittent admirustration. Br J Cancer 41: 644
`10. Prestayako AW, Croolre ST (1.978) Clinical pharmacology of
`blcomycin.
`In: Carter SK. Croolte ST, Umezawa H (eds)
`Bleomycin: Current satus and new developments. Academic
`Press, New York, p 11'?
`11. Sarnuels ML, Johnson DE, Holoye FY (1976) Bleornyciri
`combination chemotherapy programs in stage-3 testicular neopla-
`
`
`
`Bleornycinfngrfrnl)
`
`—— Patient J.N.
`
`—-— Patient U.H.
`
`
`
`1
`
`15
`
`10
`Time (hours)
`
`Fig. 1. The time course of bleomycin levels in serum from two patients
`on day] and 5 of therapy graphed on sernilog paper. Patient J. N.
`received 0.3 ml BOS IM twice daily
`Patient U. H. received
`bleomycin IV infusion 5 mg in saline solution for 4 h daily
`
`were obtained approximately 2 h after IM BOS injections. The
`infusion regimen revealed the higher peak levels, averaging
`138 ngfml vs 97 nglml in the BOS regimen (median 140 nglml vs
`90 ng/ml, respectively). The mean serum half-life was 3.5 h
`(median 3.7 h) with BOS and 2.411 (median 2.4 h) for the
`infusion (P < 0.01). Ten hours from the initiation of treatment
`on day 1 the BOS regimen revealed a mean serum level which
`was 20 nglml higher than found after the infusion. The
`corresponding difference on day 5 had increased to 31 ngfrnl.
`Before therapy on day S the serum levels achieved by BOS
`ranged from 10 ngiml to 18 ngfml compared to less than 3 ng/ml
`after infusion therapy.
`The mean distribution voiume ( VD) of bleomycin was 29.4
`um? (median 30.4 limz) with nos compared to 13.0 um?
`(median 13.1 lhnz) for the infusion (P < 0.001). The mean area
`under the serum concentration curve (AUC) obtained with
`B05 was not significantly higher than after the infusion
`regimen (57.0 mglminlml vs 49.0 mglmixuml respectively),
`despite that the BOS regimen contained almost the double
`dose of bleomycin. The mean serum clearence rate (Q) for
`B05 was 101 mlrminfmz (median 10? mlfminfmz) and 66
`mlfmin./mg (median 74 rnllminlmz) for the infusion.
`Clinically, B05 was well tolerated. Fever was seen, but
`this presented less problems than with the IV infusion. One
`patient developed a gluteal abcess, a side effect seen also in
`treatments with other depot preparations, and probably due to
`the oily vehicle. A 54-year-old woman developed a pulmonary
`fibrosis after six courses of therapy, totaling 18 ml BOS (270
`mg bleomycin) and 60 mg mitomycin-C. The symptoms were
`relieved with steroids. There were two patients with partial
`responses. Both had lung metastases, which were reduced in
`size. These effects were only short lived, such that they did not
`play a part in prolonging life.
`
`Discussion
`
`The twice daily BOS schedule revealed more favourable
`pharrnacokinetics than the 4-h infusion regimen. The lower
`
`MYLAN PHARMS. INC. EXHIBIT 1052 PAGE 2
`
`MYLAN PHARMS. INC. EXHIBIT 1052 PAGE 2
`
`

`
`276
`
`sia: Results in 101 patients. In: Carter SK, Ichikawa Tl’, Mathé G,
`Umezawa H (eds) Gama Monogr Cancer Res 19. University of
`Tokyo Press, Tokyo, 1:269
`12. Sikic BI, Collins JM, Mimnaugh EG, Gram TE (1978) Improved
`therapeutic index of hleomycin when administered by continuous
`infusion in mice. Cancer Treat Rep 62: 2011
`
`13. Slevin M1,, Harvey VJ, Aherne GW, Burton NK, Johnston A,
`Wrigley PFM (1984) Delayed-release bleomycin. Comparative
`pharmacology of bleomycin oil suspension and bleornycin in
`saline. Cancer Chemother Pharmacol 13: 19
`
`Received April 19, 1984fAcoepted October 31, 1984
`
`MYLAN PHARMS. INC. EXHIBIT 1052 PAGE 3
`
`MYLAN PHARMS. INC. EXHIBIT 1052 PAGE 3