Capecitabine Explained

Capecitabine, sold under the brand name Xeloda among others, is a anticancer medication used to treat breast cancer, gastric cancer and colorectal cancer.^[1] For breast cancer it is often used together with docetaxel. It is taken by mouth.^[2]

Common side effects include abdominal pain, vomiting, diarrhea, weakness, and rashes.^[2] Other severe side effects include blood clotting problems, allergic reactions, heart problems such as cardiomyopathy, and low blood cell counts.^[2] Use during pregnancy may result in harm to the fetus.^[2] Capecitabine, inside the body, is converted to 5-fluorouracil (5-FU) through which it acts.^[2] It belongs to the class of medications known as fluoropyrimidines, which also includes 5-FU and tegafur.^[3]

Capecitabine was patented in 1992 and approved for medical use in 1998.^[4] It is on the World Health Organization's List of Essential Medicines.^[5]

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;^[6]
• perioperative treatment of adults with locally advanced rectal cancer as a component of chemoradiotherapy;
• treatment of people with unresectable or metastatic colorectal cancer as a single agent or as a component of a combination chemotherapy regimen;
• treatment of people with advanced or metastatic breast cancer as a single agent if an anthracycline- or taxane-containing chemotherapy is not indicated;
• treatment of people with advanced or metastatic breast cancer in combination with docetaxel after disease progression on prior anthracycline-containing chemotherapy;
• treatment of adults with unresectable or metastatic gastric, esophageal, or gastroesophageal junction cancer as a component of a combination chemotherapy regimen;
• 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;
• adjuvant treatment of adults with pancreatic adenocarcinoma as a component of a combination chemotherapy regimen.

Adverse effects

Adverse effects by frequency:^{[7] [8] [9] [10]}

Very common (>10% frequency):

• Appetite loss
• Diarrhea
• Vomiting
• Nausea
• Stomatitis
• Abdominal pain
• Fatigue
• Weakness
• Hand-foot syndrome^[11]
• Oedema
• Fever
• Pain
• Headache
• Hair loss
• Dermatitis
• Indigestion
• Shortness of breath
• Eye irritation
• Myelosuppression^[12]

Notes on adverse effects:

Contraindications

Contraindications include:^[9]

• 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".^[13] 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. "^[14]

Within the UK, DPYD testing to check for this contraindication is now routine practice,^[15] this is not the case in the US.^[16]

Drug interactions

Drugs it is known to interact with include:^[9]

• 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.^[17]

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.^[3] 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.^{[3] [18]} 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.^{[3] [18]}

Mechanism of action

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.^[19]

Overdose

Uridine Triacetate is a potential antidote for cases of suspected overdose.^[20]

Society and culture

Brand names

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

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

Further reading

• Book: Medical Genetics Summaries . Capecitabine Therapy and DPYD Genotype . https://www.ncbi.nlm.nih.gov/books/NBK385155/ . Pratt VM, McLeod HL, Rubinstein WS, Scott SA, Dean LC, Kattman BL, Malheiro AJ . 3 . National Center for Biotechnology Information (NCBI) . 2016 . 28520372 . Bookshelf ID: NBK385155 . Dean L .

Notes and References

1. Book: British national formulary : BNF 69. 2015. British Medical Association. 9780857111562. 585, 588. 69.
2. Web site: Capecitabine. The American Society of Health-System Pharmacists. 8 December 2016. live. https://web.archive.org/web/20160415200439/http://www.drugs.com/monograph/capecitabine.html. 15 April 2016.
3. Caudle KE, Thorn CF, Klein TE, Swen JJ, McLeod HL, Diasio RB, Schwab M . Clinical Pharmacogenetics Implementation Consortium guidelines for dihydropyrimidine dehydrogenase genotype and fluoropyrimidine dosing . Clinical Pharmacology and Therapeutics . 94 . 6 . 640–645 . December 2013 . 23988873 . 3831181 . 10.1038/clpt.2013.172 .
4. Book: Fischer J, Ganellin CR . Analogue-based Drug Discovery. 2006. John Wiley & Sons. 9783527607495. 511. 30 August 2017. 12 January 2023. https://web.archive.org/web/20230112070704/https://books.google.com/books?id=FjKfqkaKkAAC&pg=PA511. live.
5. Book: ((World Health Organization)) . World Health Organization model list of essential medicines: 21st list 2019 . 2019 . 10665/325771 . World Health Organization . World Health Organization . Geneva . WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO . free .
6. Web site: 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 . 26 January 2023 . 27 January 2023 . https://web.archive.org/web/20230127005901/https://www.fda.gov/drugs/resources-information-approved-drugs/fda-approves-updated-drug-labeling-including-new-indications-and-dosing-regimens-capecitabine . live .
7. Web site: XELODA (capecitabine) tablet, film coated [Genentech, Inc.]]. DailyMed. Genentech, Inc.. December 2013. 25 January 2014. live. https://web.archive.org/web/20140201232002/http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=a1de8bba-3b1d-4c9d-ab8a-32d2c05e67c8. 1 February 2014.
8. Web site: Capecitabine Teva : EPAR – Product Information. European Medicines Agency. Teva Pharma B.V.. 10 January 2014. 25 January 2014. live. https://web.archive.org/web/20140204011552/http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/002362/WC500127288.pdf. 4 February 2014.
9. Web site: Capecitabine 150mg – Summary of Product Characteristics (SPC). electronic Medicines Compendium. Zentiva. 23 December 2013. 25 January 2014. dead. https://web.archive.org/web/20140201205125/http://www.medicines.org.uk/emc/medicine/28462/SPC/Capecitabine+150mg/. 1 February 2014.
10. Web site: NAME OF THE MEDICINE XELODA® Capecitabine. TGA eBusiness Services. Roche Products Pty Limited. 5 December 2013. 25 January 2014. PDF. live. https://web.archive.org/web/20170911002644/https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2010-PI-03462-3. 11 September 2017.
11. Reddening, swelling, numbness and desquamation on palms and soles
12. Includes: anaemia, lymphopenia, neutropenia and thrombocytopenia
13. Web site: ATC code . Summary of Product Characteristics (SmPC) . (emc) . 2021-04-23 . 2025-01-05.
14. Web site: FDA approves updated drug labeling including new indications . U.S. Food and Drug Administration . 2024-10-01 . 2025-01-05.
15. Web site: Robinson J . 2022-05-05 . Cancer pharmacogenomics testing: are we hitting the mark? . 2024-12-26 . The Pharmaceutical Journal . en-US.
16. Koo K, Pasternak AL, Henry NL, Sahai V, Hertz DL . Survey of US Medical Oncologists' Practices and Beliefs Regarding DPYD Testing Before Fluoropyrimidine Chemotherapy . JCO Oncology Practice . 18 . 6 . e958-e965 . June 2022 . 35239419 . 9191302 . 10.1200/OP.21.00874 .
17. Book: Rossi S . 978-0-9805790-9-3 . Australian Medicines Handbook . Adelaide . The Australian Medicines Handbook Unit Trust . 2013 . 2013 .
18. Amstutz U, Froehlich TK, Largiadèr CR . Dihydropyrimidine dehydrogenase gene as a major predictor of severe 5-fluorouracil toxicity . Pharmacogenomics . 12 . 9 . 1321–1336 . September 2011 . 21919607 . 10.2217/pgs.11.72 .
19. Web site: Xeloda (capecitabine) dosing, indications, interactions, adverse effects, and more. Medscape Reference. WebMD. 25 January 2014. live. https://web.archive.org/web/20140202175324/http://reference.medscape.com/drug/xeloda-capecitabine-342211#showall. 2 February 2014.
20. Ma WW, Saif WM, Cartwright TH, Fakih M, El-Rayes BF, King T, Vanas J, von Borstel R, Bamat MK, Posey J . Uridine triacetate as a lifesaving antidote for overdoses and severe early-onset 5-fluorouracil and capecitabine toxicities. . Journal of Clinical Oncology . 34 . 15_suppl . 2016-05-20 . 0732-183X . 10.1200/JCO.2016.34.15_suppl.e21689 . e21689–e21689.