Evaluating the Efficacy, Toxicity and Pharmacokinetic Profile of Oral Busulfan in Allogeneic Stem Cell Transplant Patients

Ross Salvaris; Sam Salman; Sean O'Halloran; David Joyce; Navin Mathew; Julian Cooney; Matthew Wright; Paul Cannell; Duncan Purtill

doi:10.31547/bct-2021-019

Evaluating the Efficacy, Toxicity and Pharmacokinetic Profile of Oral Busulfan in Allogeneic Stem Cell Transplant Patients

Blood Cell Ther. 2022 Apr 22;5(2):61-68. doi: 10.31547/bct-2021-019. eCollection 2022 May 25.

Authors

Ross Salvaris¹, Sam Salman², Sean O'Halloran³, David Joyce³, Navin Mathew¹, Julian Cooney¹, Matthew Wright¹, Paul Cannell¹, Duncan Purtill¹

Affiliations

¹ Department of Haematology, Fiona Stanley Hospital, Western Australia, Australia.
² Medical School, University of Western Australia, Western Australia, Australia.
³ Clinical Pharmacology and Toxicology, PathWest, Queen Elizabeth II Medical Centre, Western Australia, Australia.

Abstract

Background: Oral busulfan and intravenous cyclophosphamide (Bu/Cy) are common myeloablative preparations used in allogeneic hematopoietic stem cell transplantation (HSCT). Herein, we investigated the safety of (Bu/Cy) administration during HSCT.

Methods: Patients administered Bu/Cy for allogeneic HSCT at Royal Perth Hospital and Fiona Stanley Hospital between 2007 and 2017 were reviewed for inclusion in the study. We performed busulfan pharmacokinetic (PK) testing for a subset of patients and allometric scaling modeling to assess the best method of busulfan dosing in patients at extremes of weight.

Results: Sixty-nine patients were included in the clinical outcome analysis. The median follow-up period was 32 months (range, 9-114 months). The three-year overall survival rate was 62% (95% confidence interval (CI), 51%-75%), and transplant-related mortality was 4% at 6 months (95% CI, 1-7%), with a low rate of sinusoidal obstruction syndrome of the liver being observed. In addition, relapse was 38% (95% CI, 30%-44%) at 3 years. The PK information of 15 patients receiving busulfan was available after oral dosing. The average per-dose busulfan exposure was 1,350 μmol.min/L (range, 878-1,717 μmol.min/L), and the within target range was 1,000-1,500 μmol.min/L in 73% of patients. Of the size measures investigated, ideal and adjusted body weight (ABW40) provided the best fit. No association was observed between busulfan exposure, toxicity, and relapse.

Conclusions: Overall, Bu/Cy administration appeared safe when dosed in relation to weight, showing a low early transplant-related mortality rate following adequate busulfan exposure in majority of the cases. Body size measures, such as ideal body weight or ABW40, are likely more suitable for use during busulfan dosing, particularly at high extremes of the body mass index classification.

Keywords: allometric scaling; busulfan; hematopoietic stem cell transplantation; pharmacokinetics; transplantation conditioning.