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INTRODUCTION

Glucarpidase (carboxypeptidase G2, CPDG2) is indicated for the management of methotrexate (MTX) toxicity. When given intravenously or intrathecally, it rapidly enzymatically inactivates MTX, folates, and folate analogues. It does not substitute for, and must be used in conjunction with, leucovorin (Antidotes in Depth: A12). Leucovorin should not be administered within 2 hours before or after a dose of glucarpidase.

HISTORY

Soon after the description of the structure and synthesis of folate,6 a Flavobacterium species capable of removing the glutamate moiety of folate was discovered.47 From 1955 to 1956, the inactivation of folate analogues (including chemotherapeutic aminopterin) was demonstrated in bacteria and yeasts.61,92 Purification of “carboxypeptidase G,” a pseudomonad-derived zinc-dependent enzyme responsible for MTX cleavage, was reported in 1967.35,48 Other bacterial carboxypeptidases that differed in their substrate specificity and kinetics were isolated and purified in 1971 (Pseudomonas stutzeri carboxypeptidase G1),52 1978 (Flavobacterium carboxypeptidase),5 and 1992 (Pseudomonas sp. M-27 carboxypeptidase G3).104 By 1976, carboxypeptidase G1 was scaled to pilot manufacturing production.25 Carboxypeptidase G1 (CPDG1) was initially explored as a chemotherapeutic to deprive growing tumors of folate.9,10,20,42 Human usage of CPDG1 for this purpose was reported in 1974.10 The antidotal potential of carboxypeptidase was first suggested in 1972 when it was noted that CPDG1 rapidly decreased serum MTX concentrations and improved survival in mice injected with lethal MTX doses.21 Carboxypeptidase G1 was first used for rescue in a patient receiving MTX with kidney failure in 1978.40 Carboxypeptidase G1 was subsequently used to selectively eliminate systemic MTX in patients treated with high dosages targeting central nervous system (CNS) malignancies.1,2 Unfortunately, the enzyme source of CPDG1 was then lost.4,106 The carboxypeptidase currently used in clinical practice (CPDG2) was cloned from Pseudomonas strain R-16 and sequenced, characterized, and expressed in Escherichia coli in the early 1980s.57-59,81 The preliminary crystal structure was provided in 1991, with a characterization (at 2.5 Å) and description of the active site, and biochemical mechanism of action in 1997.49,74,89 Following the renewed availability of the recombinant CPDG2 product, it underwent nonhuman primate testing for both intravenous (IV) and intrathecal (IT) rescue of MTX overdose.3,4 Reports of successful use in human IV and IT MTX overdose rapidly emerged.26,40,44,45,60,62,75,97,99,106 The US FDA designated glucarpidase an Orphan Product in 2003 and granted marketing approval as Voraxaze in January 2012.16

PHARMACOLOGY

Chemistry/Preparation

Glucarpidase is produced by recombinant DNA technology. The enzyme cloned from Pseudomonas strain R16 is ...

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