CLINICAL PHARMACOKINETICS AND PHARMACOLOGY OF TRIMETREXATE

Trimetrexate represents one of a number of new antimetabolites that ha ve been studied in malignant, rheumatological and infectious disease. Methotrexate, the classical antifolate agent, is active in a broad spe ctrum of clinical settings, but its use is limited by pre-existing or acquired cellular resistance. Trimetrexate is an agent that does not r equire uptake by the folate carrier transport system, a major mechanis m of cellular resistance both in vitro and in vivo. Both dihydrofolate reductase inhibition and high performance liquid chromatography (HPLC ) assays can be used to determine drug concentrations. Clearance of tr imetrexate has been reported to follow biphasic or triphasic patterns. Elimination is primarily by biotransformation with less than 5% of th e drug excreted renally in an unchanged form. Both active and inactive metabolites have been found, but the precise metabolic pathways have yet to be defined. The role of trimetrexate in the treatment of Pneumo cystis carinii pneumonia is limited to compassionate use, as clinical studies have shown cotrimoxazole (trimethoprim-sulfamethoxazole) to be superior to trimetrexate. However, in a wide spectrum of malignant pr ocesses, trimetrexate appears to have a role either as a high-dose sin gle agent, with calcium folinate (leucovorin calcium) rescue, or in co mbination with other antineoplastic agents. However, further trials ar e needed to fully establish the efficacy of trimetrexate in these sett ings.Increased knowledge of the pattern of resistance for individual t umours and tumour types may result in trimetrexate becoming more widel y used clinically.