Isobologram analysis was used to examine the interaction between 1-fiD-arabinofuranosylcytosine (Ara-C), thymidine (dThd), and hydroxyurea. All three pairs of drugs, as well as the triple combination, were synergistic against a human B cell line in vitro across a broad range of concentrations. Synergy was associated with an increase in the Ara-C nucleotide pool and Ara-C triphosphate concentration. dThd increased, and hydroxyurea decreased, the incorporation ofAra-C into trichloroacetic acid-insoluble macromolecules per unit time. Hydroxyurea was more effective than dThd at equimolar concentrations in increasing the acid-soluble Ara-C pool. Maximal stimulation of Ara-C triphosphate formation by dThd occurred at 1 mM and was associated with reduction of the deoxycytidine triphosphate pool to 31% of control. At the same concentration, hydroxyurea increased Ara-C triphosphate formation to a greater extent but increased deoxycytidine triphosphate to 116% of control. When tested at clinically achievable concentrations on blasts from patients with acute leukemia, hydroxyurea increased the Ara-C nucleotide pool in all six cases studied, whereas dThd decreased the Ara-C nucleotide pool. These results indicate that in SB cells dThd and hydroxyurea work by different mechanisms to augment the Ara-C nucleotide pool and that hydroxyurea may be more effective than dThd as a modulator of Ara-C activity in patients with acute leukemia.1-3-D-Arabinofuranosylcytosine (Ara-C) is one of the most important drugs in the treatment of human acute leukemia (1-4). A significant increase in the selectivity of Ara-C may have farreaching consequences for the management ofthis disease. Ara-C behaves as an analog of deoxycytidine (dCyd) that, when phosphorylated to 1-,3-D-arabinofuranosylcytosine triphosphate (Ara-CTP), is a potent inhibitor of DNA polymerase (5-7) and is also incorporated into DNA (7-9). The activity of Ara-C is determined by the amount of Ara-CTP formed within the cell, and the concentration of the natural substrate deoxycytidine triphosphate (dCTP), with which Ara-CTP must compete for binding to DNA polymerase (5, 6, 10, 11).Phosphorylation of Ara-C is normally constrained by feedback inhibition ofdCTP on dCyd kinase, the enzyme catalyzing the rate-limiting step in the dCyd salvage pathway (12, 13). Thymidine (dThd) has been shown to increase the toxicity of Ara-C in vitro and in vivo against several murine (14-17) and human tumors (16). This is in part due to the ability ofthymidine triphosphate (dTTP) to inhibit ribonucleotide reductase (18), which catalyzes an obligatory step in the die novo synthesis of dCTP (19,20) and depletes the cellular dCTP pool (15,18,19,(21)(22)(23)(24)(25)(26). Hydroxyurea (HU) is also an inhibitor of mammalian ribonucleotide reductase (27), but one that binds at a different site than dTTP (28,29). HU has also been demonstrated to enhance the phosphorylation of Ara-C in murine cells (12,(30)(31)(32) and to markedly improve the therapeutic ratio ofAra-C against the murine L1210 leukemi...