Review Article
Review of Advances in Uroprotective
Agents for Cyclophosphamide- and
Ifosfamide-induced Hemorrhagic Cystitis
Ethan L. Matz and Michael H. Hsieh
Cyclophosphamide and ifosfamide are widely used drugs for malignancies and rheumatologic conditions. One of the
most significant adverse reactions to these drugs is hemorrhagic cystitis. Mesna is the most widely used uroprotective
agent that acts to neutralize the caustic metabolite, acrolein, responsible for induction of hemorrhagic cystitis. However,
mesna is not a perfect alternative, and studies since its discovery have investigated the use of alternative drugs and ad-
juncts to increase mesna’s efficacy. This review details some of the recent work into novel uroprotective agents for drug-
induced hemorrhagic cystitis. UROLOGY 100: 16–19, 2017. © 2016 Elsevier Inc.
C
yclophosphamide and ifosfamide (Figs. 1 and 2)
are oxazaphosphorine agents approved by the Food
and Drug Administration (FDA) for use against
a number of malignancies and benign diseases. Cancers
treated with cyclophosphamide or ifosfamide include both
childhood and adult onset. Cyclophosphamide and
ifosfamide are prescribed for pediatric cancers including
acute lymphoblastic leukemia, neuroblastoma, and reti-
noblastoma. Minimal-change nephrotic syndrome is treated
with cyclophosphamide. In adults, cyclophosphamide is ap-
proved for use in acute myelogenous leukemia, breast
cancers, chronic lymphocytic leukemia, Hodgkin’s lym-
phoma, multiple myeloma, mycosis fungoides, non-Hodgkin
lymphoma, and ovarian adenocarcinoma. Cyclophospha-
mide also has a role as an immunosuppressant in hema-
topoietic stem cell transplantation.1,2 Moreover, ifosfamide
is FDA-indicated for use against testicular germ cell tumors.3
It has therapeutic efficacy in small-cell and non–small cell
lung cancers, bladder cancer, non-Hodgkin lymphoma, and
advanced breast cancer.4 As demonstrated above, the use
of these oxazaphosphorine drugs is wide and encompasses
a vast number of patients. Based on American Cancer
Society estimates of cancer incidence, the incidence of neo-
plasms with an FDA indication of cyclophosphamide is more
than 400,000 new patients a year.5
Hemorrhagic cystitis is a sterile, noninfectious cystitis
primarily induced by ifosfamide and cyclophosphamide.
Ifosfamide may be particularly prone to inducing this
Financial Disclosure: The authors declare that they have no relevant financial
interests.
From the School of Medicine and Health Sciences, The George Washington Univer-
sity, Washington, DC; the Clinic for Adolescent and Adult PedIatric OnseT UroLogy
(CAPITUL), Children’s National Medical Center, Washington, DC; and the George
Washington University, Washington, DC
Address correspondence to: Ethan L. Matz, B.S., School of Medicine and Health Sci-
ences, The George Washington University, 111 Michigan Ave. NW, Washington, DC.
E-mail: ematz@gwu.edu
Submitted: April 19, 2016, accepted (with revisions): July 26, 2016
16 © 2016 Elsevier Inc.
All rights reserved.
complication.6 Cyclophosphamide, as a cause of hemor-
rhagic cystitis, was first described by a German group in
1958 and later examined by Watson and Notley in 1973.7,8
They noted that 10%-40% of patients on cyclophospha-
mide developed hemorrhagic cystitis, which sometimes
abated on the withdrawal of the offending agent.9 In 1 study
on the use of cyclophosphamide in rheumatic disease, Yilmaz
et al found that of 1018 patients, about 1.5% developed
hemorrhagic cystitis.10 In a 1975 study of children treated
with cyclophosphamide for leukemia, 25 cases of hemor-
rhagic cystitis were observed among 314 patients. 11
Cyclophosphamide- and ifosfamide-induced hemorrhagic
cystitis remains an important clinical problem today.
In general, mild hemorrhagic cystitis can be managed
on an outpatient basis with hydration and is transient in
nature. Moderate hemorrhagic cystitis can require clot ex-
traction via cystoscopy, continuous bladder irrigation, and
instillation of agents into the bladder. Severe hemor-
rhagic cystitis can require inpatient management with trans-
fusions and major procedures, including cystectomy.
Some of the molecular mechanisms of cyclophosphamide-
and ifosfamide-induced hemorrhagic cystitis have been
defined, and therapeutic targets may exist within these path-
ways. During hepatic metabolism of cyclophosphamide and
ifosfamide, acrolein is generated, filtered by the kidneys, and
concentrated in the bladder. This metabolite causes a
pyroptotic reaction in the bladder urothelium that in turn
leads to ulceration. Acrolein induces cell death through
upregulation of reactive oxygen species (ROS). Acrolein also
activates inducible nitric oxide synthase, leading to the pro-
duction of nitric oxide.12,13 Both ROS and nitric oxide produce
peroxinitrates, which attack lipids and proteins.14 They are
also responsible for breaking DNA strands, ultimately re-
sulting in cessation of protein production.15 ROS produc-
tion induces transcription factors including NF-κB and
activator protein 1, which stimulate proinflammatory cytokine
(tumor necrosis factor-alpha [TNF-α] and interleukin-1beta
http://dx.doi.org/10.1016/j.urology.2016.07.030
0090-4295

Figure 1. The chemical structure of cyclophosphamide.34
(Color version available online.)
Figure 2. The chemical structure of ifosfamide.35 (Color
version available online.)
[IL-1β]) gene expression.16 Thus, cyclophosphamide and
ifosfamide induce hemorrhagic cystitis through various cas-
cades, which converge on acrolein and its effects.
Once cyclophosphamide- and ifosfamide-induced hem-
orrhagic cystitis has occurred, there are a few good treat-
ment options. These options include continuous bladder
irrigation, aluminum potassium sulfate and formalin in-
stillation, fulguration, hyperbaric oxygen, and in extreme
cases, cystectomy. Intravesical infusion of aluminum po-
tassium sulfate and formalin acts as chemical corrosives
causing coagulation through protein precipitation and
protein hydrolysis, respectively.17 Hyperbaric oxygen can
cause vasoconstriction and fibrosis.18 Moreover, none of
these treatment options is completely efficacious. In short,
prevention of cyclophosphamide- and ifosfamide-induced
hemorrhagic cystitis is preferred over treatment of estab-
lished disease.
An important agent that protects against cyclophosphamide-
and ifosfamide-induced hemorrhagic cystitis is mesna. In 1983,
Brock and Pohl defined the mechanism of action of mesna
and its potential use as a uroprotective agent with concur-
rent use of cyclophosphamide.8 Mesna (sodium-2-
mercaptoethanesulfonate) (Fig. 3) is a thiol compound that
is metabolized to dimesna and excreted by the kidneys. The
reabsorbed portion is acted on by glutathione dehydroge-
nase and generates free sulfhydryl groups, which binds acro-
lein in the bladder, leading to effective excretion.4,6 Throughout
the years, varying dosages and timings of mesna and
UROLOGY 100, 2017
Figure 3. The chemical structure of mesna.36 (Color version
available online.)
hyperhydration have been tested as prophylaxis against hem-
orrhagic cystitis. In 2002, the American Society of Clinical
Oncology established clinical practice guidelines for the use
of mesna. These guidelines suggest that for a standard dose
of ifosfamide <2.5 g/m2/d, dosing of mesna should equal 60%
of the total daily dose of ifosfamide and divided between 3
bolus doses, administered 15 minutes before and 4 and 8 hours
after the administration of each dose of ifosfamide. For cy-
clophosphamide administered in the setting of bone marrow
transplantation, mesna plus saline diuresis is recommended
to prevent hemorrhagic cystitis.19
In 1991, Shepherd et al proposed the use of hyperhydration
instead of mesna as a more cost-effective uroprotective agent.
They concluded that based on a randomized trial of 100 pa-
tients, hyperhydration is noninferior to mesna in prevent-
ing hemorrhagic cystitis in recipients of bone marrow
transplant.20 In 1999, Ballen et al also seconded the use of
hyperhydration as an alternative to mesna and bladder ir-
rigation. They hydrated study subjects with 5% dextrose in
normal saline at 250 mL/h and furosemide to maintain a urine
output of >150 mL/h. They determined that hyperhydration
is a safe and inexpensive preventative measure for hemor-
rhagic cystitis in patients treated with cyclophosphamide for
bone marrow transplantation.21 However, hyperhydration may
not be possible in patients with renal, lung, or liver dys-
function because of risks of fluid overload.20 In a 2003 article,
Mank et al discussed the dangers of fluid overload in pa-
tients where hyperhydration is used and the need for daily
weights to assess fluid status.22 Thus, hyperhydration is not
an ideal alternative to mesna.
Moreover, mesna has not been a panacea for hemor-
rhagic cystitis. Yilmaz and colleagues determined that within
their cohort of patients treated with cyclophosphamide for
rheumatic diagnoses there was no uroprotective effect of
mesna (1.53% rate of hemorrhagic cystitis with mesna treat-
ment vs 1.8% without mesna, P = .08).10 In addition, mesna
has been associated with significant adverse effects. In 2007,
Khaw et al reported a hypersensitivity-like cutaneous and
systemic reaction to mesna.23 Subsequently, in 2007, Lima
et al examined the histologic changes of the mesna- and
ifosfamide-exposed bladder. They found that even with 3
doses of pretreatment mesna, 66.7% of patients showed
pathologic changes of the bladder wall during cystoscopy
and all exhibited microscopic lesions such as edema, exo-
cytosis, and hemorrhage. Therefore, even with standard regi-
mens of mesna prophylaxis, there are urothelial and mucosal
changes following ifosfamide exposure.24 Clearly, there is
a need for alternative uroprotective agents.
Many uroprotective agents have shown promising results
in animal models but have not transitioned to clinical trials.
17
Keles et al described the use of resveratrol, a grape deriva-
tive with antioxidant effects, to ameliorate the effects of
cyclophosphamide-induced ROS in the bladder. They dem-
onstrated that 20 and 40 mg/kg of resveratrol conferred both
biochemical and histopathologic protective effects against
cyclophosphamide-induced hemorrhagic cystitis. However,
when compared with mesna, the results were inferior.16 Leite
et al used anakinra, an IL-1 receptor blocker, and infliximab,
a TNF inhibitor, to attenuate cyclophosphamide-induced
hemorrhagic cystitis in rodents. They found that anakinra
controlled hemorrhage and mitigated inflammatory and func-
tional bladder parameters. However, infliximab failed to show
significant benefit. They postulated that infliximab’s failure
was due to TNF signaling through only the TNFR2 recep-
tor. TNF signaling in the bladder is transduced through the
TNFR1 and TNFR2 receptors. TNFR1 and TNFR2 signal-
ing are associated with cell death and survival, respectively.25
These findings point to the complexity of cyclophosphamide-
and ifosfamide-induced hemorrhagic cystitis.
The molecular intricacy of chemotherapy-induced hem-
orrhagic cystitis is also highlighted by the multifaceted in-
volvement of proinflammatory immune responses. For
instance, the mitogen-activating kinases (MAPKs) poten-
tiate the proinflammatory response triggered by cyclophos-
phamide and ifosfamide. In 2015, Kim et al described that
ROS produced by acrolein in the bladder activate MAPKs.
Diallyl disulfide (DADS) produced from garlic oil in-
creases the antioxidant enzymatic activities that scav-
enge ROS. DADS also acts as an anti-inflammatory
mediator by downregulating MAPK signaling pathways and
NF-κB. They demonstrated that DADS inhibits
cyclophosphamide-induced hemorrhagic cystitis by sup-
pressing urine inducible nitric oxide synthase and
cyclooxygenase 2 protein expression in the bladder, thereby
attenuating ROS-induced damage. 26 Abo-Salem ex-
plored the use of pentoxifylline, a nonspecific phosphodi-
esterase inhibitor that downregulates proinflammatory
cytokines, as a potential prophylactic for chemotherapy-
induced hemorrhagic cystitis. This work concluded that
pentoxifylline reduces cyclophosphamide-induced hemor-
rhagic cystitis through antioxidant and anti-inflammatory
effects.27 In conclusion, numerous proinflammatory path-
ways initiated by cyclophosphamide and ifosfamide may be
therapeutic targets for hemorrhagic cystitis.
Understanding that proinflammatory cytokines have an
important influence on the development of hemorrhagic
cystitis, Vieira et al directed their work to reduce or block
these actions. They first investigated the effect of gluco-
corticoids on the release of proinflammatory cytokines.
Dexamethasone was used both as monotherapy and as an
adjunct to mesna to determine bladder effects. They de-
termined that replacing 1 or 2 doses of mesna with dexa-
methasone was as effective as an entire series of mesna.
However, dexamethasone as monotherapy was not infe-
rior, and glucocorticoids as a class have contraindications
with certain cancers, whereby influencing response to
treatment.28 Macedo, an investigator from the above pub-
lication, and his colleagues recently examined the role IL-4
18
plays as a modulator to the proinflammatory cascade and
its potential role in cyclophosphamide-induced hemor-
rhagic cystitis. IL-4 inhibits monocyte-derived cytokines,
such as IL-1B, IL-6, IL-8, and TNF. IL-4 can also reduce
the induction of cyclooxygenase 2, which subsequently in-
hibits prostaglandin release. They determined that IL-4 was
produced in greater amounts after ifosfamide administra-
tion and that intraperitoneal injection of IL-4 reduced both
edema and hemorrhage in the bladder. However, IL-4 was
effective only at high doses, possibly because of its binary
effects on both pro- and anti-inflammatory cascades.29
Besides targeting proinflammatory cascades, redox- and
anesthetic-based approaches show promise to prevent
chemotherapy-associated hemorrhagic cystitis. Two 2014 ar-
ticles in the Indian Journal of Pharmacology address possible
therapeutics for uroprotection against ifosfamide-induced
hemorrhagic cystitis. The first publication examined the ad-
juvant use of reduced glutathione with mesna in ifosfamide-
treated rodents. The authors concluded that glutathione has
the potential to be at least as useful as mesna in patients being
treated with ifosfamide.30 The second article studied the
effects of a single dose of ketamine combined with mesna
in ifosfamide-exposed rats. These investigations showed that
ketamine combined with mesna reduced bladder wet weight,
and that ketamine alone prevents microscopic changes as-
sociated with hemorrhagic cystitis.31 Interestingly, ketamine
abuse can itself lead to extensive cystitis.32 Hence, focus-
ing on preventing chemotherapy-induced hemorrhagic cys-
titis through use of ketamine and other potential drugs of
abuse may be suboptimal.
Alternative potential prophylactics for cyclophosphamide-
and ifosfamide-induced hemorrhagic cystitis may exist in
the natural world. Specifically, Uncaria tomentosa is a na-
turopathic medicine derived from a plant in the Rubiaceae
family and is used for urinary tract disease. U. tomentosa
was studied by Dietrich et al in cyclophosphamide-
induced hemorrhagic cystitis. They investigated quinovic
acid glycosides purified fractions (QAPF) from U. tomentosa
and its interaction with the P2X7 purine receptor, which
is expressed in the bladder. The authors suggest that QAPF
downregulates the P2X7 receptor, leading to decreased levels
of IL-1β in the bladder. They also postulated that QAPF
may complex with acrolein, thereby inactivating it. The
authors concluded that this 2-pronged method of reduc-
ing the effects of cyclophosphamide on the bladder could
lead to decreased incidence of cyclophosphamide-induced
hemorrhagic cystitis.33 Dietrich et al’s work suggests that
products found in nature may have value as uroprotective
agents for chemotherapy-induced hemorrhagic cystitis.
Cyclophosphamide- and ifosfamide-induced hemor-
rhagic cystitis remains a prevalent problem in the setting
of treatment of a multitude of oncologic and rheumatologic
conditions. Since the discovery of mesna and hyper-
hydration as uroprotective agents, investigators have sought
to develop agents with superior efficacy and fewer side
effects. Efforts targeting proinflammatory cascades and oxi-
dation seem to have shown the most promise. However,
no level 1 evidence has shown results superior to mesna
UROLOGY 100, 2017
for uroprotection against cyclophosphamide- and ifosfamide-
induced hemorrhagic cystitis. Clearly, additional re-
search is needed to develop prophylactics against this
devastating complication of chemotherapy.
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