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Forty-seven patients with advanced malignancies were treated with a concurrent 72-h continuous infusion of 5-fluorouracil (FUra) and dipyridamole. The FUra dose was escalated over the dose range of 185 to 3600 mg/m2/day for 3 days. Dipyridamole was administered in a fixed dose of 7.7 mg/kg/day for 3 days. A total of 155 courses of therapy were completed of which there were 31 paired courses of the combination and FUra alone, at the same dose of FUra and in the same patient. This was for purposes of analysis of pharmacokinetics and modulation of FUra toxicity by dipyridamole. Stomatitis was the dose-limiting toxicity experienced by patients entered into this trial. Myelosuppression was not a serious problem. Increasing FUra plasma concentration was associated with greater leukopenia and stomatitis. Dipyridamole did not appear to modulate the systemic toxicity of FUra. The pharmacokinetics of FUra were altered by the concurrent administration of dipyridamole. Dipyridamole promoted the total body clearance of FUra which resulted in lower mean steady-state FUra plasma concentrations when compared with courses of FUra alone administered at the same dose level. These differences were statistically significant over the course of the trial. For courses of the combination, FUra exhibited linear pharmacokinetics over the dose range studied. Total body clearance of FUra declined slightly at the higher dose levels, but the differences were not significant. For courses of FUra alone, total body clearance was significantly decreased above the dose level of 2300 mg/m2/day. At the maximal tolerated dose of FUra, 2300 mg/m2/day x3, mean steady-state FUra plasma concentration and total body clearance were 6.6 microM and 122 liters/h/m2, respectively, for courses of the combination. The corresponding pharmacokinetic parameters were 7.4 microM and 103 liters/h/m2 for courses when FUra was given alone. Further evaluation of the utility of this regimen and basis of these pharmacokinetic observations appear warranted.

Although the interaction between FUra and DP in HCT 116 cells is fairly complex, data from other investigators indicate that in cell lines in which inhibition of TS is growth limiting at relatively low concentrations of fluoropyrimidines, DP appears to augment the cytotoxicity of FUra and FdUrd by blocking the salvage of dThd (Miller et al., 1987; Schwartz et al., 1987). The previous in vitro data regarding the ability of DP to modulate the toxicity of fluoropyrimidines was obtained in exponentially growing cells. An additional observation that warrants consideration is a report that the inhibition of nucleoside incorporation by DP changed as a function of time in culture (Zhen et al., 1986). Hepatoma 3924A cells in lag and log phase were highly sensitive to DP with IC50 values for dThd incorporation of 0.2 and 0.32 microM, respectively. In contrast, stationary phase cells were insensitive to DP (IC50 = 38.9 microM). Amphotericin B, an antifungal agent which perturbs cell membranes, restored the sensitivity to DP in stationary cells. Several investigators have presented information on the effect of DP on fluoropyrimidines in normal tissues. Lee and Park (1987) examined the effect of DP on FUra and MTX toxicity in a soft-agar cloning assay against two human cancer cell lines and on pooled normal human bone marrow (CFU-C). DP (1 microM) potentiated the action of both MTX (0.1 microM) and FUra (5 microM) on Hep-2 (epidermoid carcinoma), MCF-7 (breast carcinoma) and CFU-C in medium supplemented with either non-dialyzed or dialyzed serum. Woodcock et al. (1987) incubated gallbladder mucosa, obtained from patients undergoing elective surgery for cholelithiasis, with control medium or varying concentrations of DP for 1 hr, and then exposed the mucosal cells to 2.5 microCi [3H]-FdUrd (2.5 microM). After 1 hr, the uptake of FdUrd into the tissue was inhibited to 49% and 42% of control by 0.1 microM and 1 microM, respectively.

This study was undertaken to determine if salvage of nucleic acid precursors might constitute a mechanism of resistance to acivicin in human colon cancer cells and, if so, to establish whether dipyridamole, an inhibitor of nucleoside and nucleobase transport, can block the salvage process and restore sensitivity to acivicin. Acivicin inhibited the replication of human colon cancer cells (VACO 5) in vitro in a dose- and time-dependent fashion. In addition, marked cell lysis was evident after a 24-hr exposure to acivicin at concentrations greater than 1 microgram/ml. The primary metabolic effect of acivicin was depletion of the cytidine triphosphate and guanosine triphosphate pools. Adenosine triphosphate levels were also reduced, but apparently as a consequence of the guanosine triphosphate depletion. VACO 5 cells exposed to acivicin (3 micrograms/ml) efficiently salvaged low levels (1 micron) of cytidine, guanosine, and guanine and could, therefore, restore the depleted nucleotide pools. The combination of cytidine and guanosine, but not either nucleoside alone, provided significant protection against the growth-inhibitory properties of acivicin. Dipyridamole, at a noncytotoxic concentration (5 microM), blocked repletion of the cytidine triphosphate and guanosine triphosphate pools in cells exposed to acivicin and the nucleic acid precursors. As a result, the growth-inhibitory effects of acivicin were maintained. The salvage of cytidine was particularly sensitive to inhibition by dipyridamole, and no restoration of cytidine triphosphate pools was evident. The cellular uptake of a variety of nucleic acid precursors was differentially sensitive to inhibition by dipyridamole. The 50% inhibitory dose values ranged from 0.01 to 2.5 microM for cytidine and uridine, respectively. The results of this study indicate that, although the replication of VACO 5 cells was inhibited by acivicin, low levels of nucleosides and nucleobases can circumvent the cytotoxicity. Dipyridamole effectively blocked the salvage pathways and restored the sensitivity of the cancer cells to the antiproliferative actions of acivicin.

The effect of dipyridamole (DP), an inhibitor of nucleoside transport, on the uptake and toxicity of 5-fluorouracil (FUra) was examined in a human colon cancer cell line (HCT 116). DP substantially increased the cytotoxicity of FUra in cell growth experiments and in viability assays measuring colony formation. The augmentation by DP was dose and time dependent. Several possible mechanisms by which DP enhanced FUra toxicity were investigated. DP did not alter the uptake of FUra into the acid-soluble and -insoluble fractions of HCT 116 cells. While DP did not affect the uptake of FUra, it did inhibit the transport of the nucleoside analogues, fluorouridine and fluorodeoxyuridine, of FUra. Although DP effectively inhibited the uptake of thymidine and uridine in a dose-dependent manner, several lines of evidence suggested that inhibition of nucleoside salvage was not the critical effect. (a) The toxicity of FUra was not prevented by thymidine, uridine, or the combination of thymidine and uridine. Thymidine triphosphate pools, decreased by 50% during the initial 8 h of exposure to FUra, were not further depleted by the addition of DP. The shrinkage in deoxythymidine triphosphate pools produced by FUra was prevented by concomitant exposure to thymidine; however, this did not translate into protection from FUra lethality. The use of dialyzed serum, which greatly diminished the availability of nucleic acid precursors, did not increase the toxicity of FUra. DP increased the cytotoxicity of FUra as effectively in experiments utilizing dialyzed serum as when nondialyzed serum was used. Surprisingly, however, the addition of sufficient thymidine to overcome the DP block did prevent the augmentation of FUra toxicity produced by DP. DP may provide a novel means of enhancing the cytotoxicity of FUra.

In HCT 116 cells, a human colon cancer cell line, the levels of thymidine (0.6 microM) and hypoxanthine (9 microM) contributed to the tissue culture medium by the fetal bovine serum significantly reduced the growth inhibition and lethality produced by 0.1 microM methotrexate. Dipyridamole, an inhibitor of nucleoside transport, potentiated the growth inhibitory effects of methotrexate when the cells were grown in medium that was changed daily. However, when the medium was supplemented with dialyzed serum, methotrexate cytotoxicity was not increased by dipyridamole. Similarly, in cloning experiments, dipyridamole increased the cell killing produced by methotrexate. The potentiation of methotrexate toxicity produced by dipyridamole was mediated through inhibition of thymidine uptake. The uptake of 1 microM thymidine was inhibited 50% by 0.12 microM dipyridamole but neither hypoxanthine nor guanine uptake was decreased by dipyridamole (5 microM). As a result, the decrease in dTTP pools produced by methotrexate was augmented by dipyridamole. In contrast, dipyridamole did not influence the effect of methotrexate on ribonucleoside triphosphate pools. HCT 116 cells avidly salvaged low concentrations of thymidine, and methotrexate increased this capacity. Conversion of 0.11 microM thymidine to thymidine triphosphate was increased by 55%, from 16.6 to 25.7 pmoles/10(6) cells, following exposure to 1.0 microM methotrexate. Dipyridamole blocked this pool expansion. This study suggests that the salvage of physiological levels of thymidine may diminish the cytotoxic effects of methotrexate on human colon cancer cells. Inhibition of thymidine uptake by dipyridamole may be an effective strategy to increase the cytotoxicity of methotrexate.

We have carried out a clinical trial in 23 patients to determine whether dipyridamole modulates the clinical effect of methotrexate. This trial was based upon in vitro studies which indicate that dipyridamole potentiates the cytotoxic action of methotrexate through inhibition of thymidine salvage. Methotrexate was given as a bolus injection 24 h after initiation of a high dose dipyridamole infusion. The trial was designed so that methotrexate was escalated in individuals until toxicity occurred and then the methotrexate dose resulting in toxicity was repeated without dipyridamole. During the course of this study the methotrexate dose was escalated from 10 to 130 mg/m2. While individual patient tolerance varied, moderate to severe myelosuppression and/or mucositis occurred frequently in patients receiving the combination with methotrexate doses greater than or equal to 60 mg/m2. Ten of 10 patients who experienced moderate or severe toxicity with the combination had significantly less toxicity when treated with methotrexate alone. Dipyridamole did not increase toxicity by an alteration in methotrexate elimination. The potentiation of methotrexate by dipyridamole in these patients suggests that physiological thymidine levels are sufficient to perturb the clinical effects of methotrexate and that thymidine salvage may represent a mechanism for clinical resistance to methotrexate. These results also suggest that a high dose dipyridamole regimen can be used as a pharmacological approach to test the role of nucleoside membrane flux on the clinical action of other standard chemotherapeutic drugs. Phase II studies testing the clinical efficacy of this combination should use a methotrexate dose of 60 mg/m2 with a provision for methotrexate dose escalation based upon individual patient tolerance.

We have reported previously that dipyridamole increases the toxicity of 5-fluorouracil and alters fluorouracil metabolism in HCT 116 cells, producing a selective increase in fluorodeoxyuridine monophosphate (FdUMP) levels by blocking the efflux of fluorodeoxyuridine. Dipyridamole also blocks deoxyuridine efflux and prolongs the intracellular half-life of deoxyuridine monophosphate (dUMP). The significance of the effect of dipyridamole on FdUMP and dUMP levels was explored further. In cell growth experiments, 1-50 microM deoxyuridine enhanced the cytotoxicity of 5 microM fluorouracil in a dose-dependent manner, and greater than or equal to 10 microM deoxyuridine increased the augmentation of fluorouracil toxicity produced by 0.5 microM dipyridamole. The effect of deoxyuridine on [6-3H]fluorouracil metabolism was studied. After 4 hr, 25 microM deoxyuridine increased the amount of [3H]FdUMP formed 2- to 4-fold relative to that of fluorouracil +/- dipyridamole alone. The mechanism by which deoxyuridine increased FdUMP was examined by measuring the distribution of [2'-3H]deoxyuridine metabolites following exposure of 25 microM deoxyuridine +/- 5 microM fluorouracil. Tritium appeared in the FdUMP peak at 4 and 24 hr in cells exposed to fluorouracil and deoxyuridine, indicating that [3H]deoxyribose was transferred to fluorouracil. A large buildup of [3H]dUMP was seen in cells exposed to fluorouracil plus deoxyuridine for 4 and 24 hr compared to exposure to [3H]deoxyuridine alone, suggesting that dUMP may also inhibit catabolism of FdUMP. Since the increased FdUMP levels produced by dipyridamole did not appear to correlate with further depletion of thymidine triphosphate pools, the incorporation of [3H]fluorouracil metabolites into nucleic acids was monitored by cesium sulfate density centrifugation. Fluorouracil-RNA increased as a function of time (1, 2 and 13 pmol/10(6) cells after 4, 8 and 24 hr), but fluorouracil-DNA was detected only after 24 hr (0.5 pmol/10(6) cells). Dipyridamole however, did not appear to alter the pattern of incorporation of fluorouracil into either RNA or DNA. Perturbations of endogenous dUMP levels by fluorouracil and dipyridamole were then studied. In cells exposed to fluorouracil alone, dUMP pools were unchanged from control at 2 hr, but they had increased 9-fold by 4 hr (3362 pmol/10(6) cells). Simultaneous exposure to fluorouracil and dipyridamole resulted in a 1.5-fold (566 pmol/10(6) cells) and 13.6-fold (5049 pmol/10(6) cells) increase over control dUMP levels after 2 and 4 hr respectively. The dUMP pools continued to enlarge through 24 hr. The effect of fluorouracil on DNA fragility was examined.(ABSTRACT TRUNCATED AT 400 WORDS)

The nucleoside transport inhibitor dipyridamole can increase the cytotoxicity of 5-fluorouracil in a human colon cancer cell line (HCT 116) without affecting the total amount of fluorouracil incorporated into the acid soluble and insoluble fractions (J. L. Grem and P. H. Fischer, Cancer Res., 45: 2967-2972, 1985). We now report that dipyridamole altered the pattern of fluorouracil metabolism and provided a selective increase in intracellular fluorodeoxyuridine monophosphate (FdUMP) levels. At 2 and 4 h after exposure to fluorouracil and dipyridamole, FdUMP levels were approximately 5-fold higher in the presence of dipyridamole. The ratio of FdUMP to fluorouridine triphosphate at 4 h was substantially increased in the presence of dipyridamole (0.4 +/- 0.05) compared to fluorouracil alone (0.08 +/- 0.03). In cells preloaded with fluorodeoxyuridine (FdUrd), dipyridamole potently inhibited the efflux of FdUrd, leading to an increased retention of intracellular FdUMP. One h following removal of [6-3H]FdUrd, the FdUMP levels were increased 8-fold in the presence of dipyridamole, and the half-life of intracellular FdUMP was increased from 24 to 78 min. We have previously shown that the addition of sufficient thymidine (25 microM) can prevent the augmentation of fluorouracil toxicity produced by dipyridamole. In these studies, the addition of 25 microM thymidine reduced the FdUMP levels to less than half of those measured in the presence of fluorouracil plus dipyridamole for the first 8 h of exposure, and reduced the FdUMP levels to 6% of the FdUMP levels seen with fluorouracil and dipyridamole after 24 h of exposure. Thymidine prevented the enhanced intracellular retention of FdUMP produced by dipyridamole in cells preloaded with FdUrd. In addition, thymidine inhibited the accumulation of FdUMP in cells exposed to FdUrd. In cancer cells which significantly catabolize FdUMP, the ability of dipyridamole to block the efflux of FdUrd may provide an effective means of selectively increasing FdUMP levels and enhancing the toxicity of fluorouracil. Furthermore, dipyridamole blocked the efflux of deoxyuridine and prolonged the intracellular half-life of deoxyuridine monophosphate. In cells prelabeled with [2'-3H]dUrd, transfer of tritium to FdUrd and FdUMP occurred in cells exposed to fluorouracil and dipyridamole. These data suggest that blockade of nucleoside efflux can enhance the availability of deoxyribose-1-phosphate donors for the synthesis of FdUrd. Thus, dipyridamole's ability to inhibit nucleoside transport can perturb the metabolism of a nucleobase, fluorouracil.