A narrative review of metabolomics approaches in identifying biomarkers of doxorubicin-induced cardiotoxicity

BACKGROUND: While anthracyclines, commonly used in cancer treatment, are well known to cause cardiotoxicity, no validated biomarkers currently exist that can predict the early development of doxorubicin-induced cardiotoxicity (DIC). Therefore, identifying early biomarkers of DIC is urgently needed. Metabolomics approaches have been used to elucidate this relationship and identified related metabolite markers. However, differences in pre-clinical model systems make it challenging to draw definitive conclusions from the discoveries and translate findings into clinical applications. AIM OF REVIEW: A systematic literature search on metabolomics studies of DIC was conducted with the goal to identify and compare study results reported using in vitro models, animal models, and studies from clinical patients. Metabolites identified across all studies were pooled to uncover biologically meaningful patterns that are significantly enriched in the data. Finally, pooled metabolites perturbed by DIC were mapped to metabolic pathways to explore potential pathological implications. RESULTS: We reviewed 28 studies published between 2000 and 2024 that utilized metabolomics approaches to investigate DIC. The included studies used a variety of analytical techniques, including LC-MS, GC-MS, and NMR. The analysis revealed that metabolites such as inosine, phenylalanine, arginine, and tryptophan were commonly perturbed across all study models, with carnitine metabolism and purine and pyrimidine metabolism being the most affected pathways. Metabolite Set Enrichment Analysis (MSEA) using MetaboAnalyst identified the arginine biosynthesis, citrate cycle, and alanine, aspartate, and glutamate metabolism pathways as significantly enriched. CONCLUSION: These findings underscore the potential of metabolomics in identifying early biomarkers for DIC, providing a foundation for future studies aimed at preventing cardiotoxicity and improving treatment strategies for cancer patients receiving DOX-containing therapies. KEY SCIENTIFIC CONCEPTS OF REVIEW: Altogether, metabolomics studies suggest metabolic alterations in DIC, albeit little overlap between studies especially with animal and human studies. Attempts at intercepting these pathways have shown that intervention in DIC may be possible. Future research should focus on developing precise cardiotoxicity models that incorporate cancer metabolism, as these will be crucial in bridging the gap between laboratories (in vitro and animal models) and clinical studies to identify subclinical biomarkers in the early stage of DIC that can effectively identify new targets for interventions to reduce lethal cardiovascular disease risk.