In clinical practice, 25-30% of the patients treated with fluoropyrimidines experience severe fluoropyrimidine-related toxicity. Extensively clinically validated DPYD genotyping tests are available to identify patients at risk of severe toxicity due to decreased activity of
dihydropyrimidine dehydrogenase (DPD), the rate limiting
enzyme in fluoropyrimidine metabolism. In April 2020, the European Medicines Agency recommended that, as an alternative for DPYD genotype-based testing for
DPD deficiency, also phenotype testing based on pretreatment plasma
uracil levels is a suitable method to identify patients with
DPD deficiency. Although the evidence for genotype-directed dosing of fluoropyrimidines is substantial, the level of evidence supporting plasma
uracil levels to predict DPD activity in clinical practice is limited. Notwithstanding this,
uracil-based phenotyping is now used in clinical practice in various countries in Europe. We aimed to determine the value of pretreatment
uracil levels in predicting
DPD deficiency and severe treatment-related toxicity. To this end, we determined pretreatment
uracil levels in 955 patients with
cancer, and assessed the correlation with DPD activity in peripheral blood mononuclear cells (PBMCs) and fluoropyrimidine-related severe toxicity. We identified substantial issues concerning the use of pretreatment
uracil in clinical practice, including large between-center study differences in measured pretreatment
uracil levels, most likely as a result of pre-analytical factors. Importantly, we were not able to correlate pretreatment
uracil levels with DPD activity nor were
uracil levels predictive of severe treatment-related toxicity. We urge that robust clinical validation should first be performed before pretreatment plasma
uracil levels are used in clinical practice as part of a dosing strategy for fluoropyrimidines.