Characterization of Dexloxiglumide in vitro Biopharmaceutical Properties and Active Transport

Physiologically Based Biopharmaceutics Modeling of regional and colon absorption in humans

Colon absorption is a key determinant for successful development of extended release and colon targeted drug products. This is the first systematic evaluation of the ability to predict in vivo regional differences in absorption and the extent of colon absorption in humans using mechanistic physiologically based biopharmaceutics modeling (PBBM). A new dataset, consisting of 19 drugs with a wide range of biopharmaceutics properties and extent of colon absorption in humans, was established. Mechanistic predictions of the extent of absorption and plasma exposure after oral, or jejunal and direct colon administration were performed in GastroPlus and GI-Sim using an a priori approach. Two new colon models developed in GI-Sim, were also evaluated to assess if the prediction performance could be improved. Both GastroPlus and GI-Sim met the pre-defined criteria for accurate predictions of regional and colon absorption for high permeability drugs irrespective of formulation type, while the prediction performance was poor for low permeability drugs. For solutions, the two new GI-Sim colon models improved the colon absorption prediction performance for the low permeability drugs while maintaining the accurate prediction performance for the high permeability drugs. In contrast, the prediction performance decreased for non-solutions using the two new colon models. In conclusion, PBBM can be used with sufficient accuracy to predict regional and colon absorption in humans for high permeability drugs in candidate selection as well as early design and development of extended release or colon targeted drug products. The prediction performance of the current models needs to be improved to allow high accuracy predictions for commercial drug product applications including highly accurate predictions of the entire plasma concentration-time profiles as well as for low permeability drugs.

A novel approach for predicting P-glycoprotein (ABCB1) inhibition using molecular interaction fields

P-glycoprotein (Pgp or ABCB1) is an ABC transporter protein involved in intestinal absorption, drug metabolism, and brain penetration, and its inhibition can seriously alter a drug's bioavailability and safety. In addition, inhibitors of Pgp can be used to overcome multidrug resistance. Given this dual purpose, reliable in silico procedures to predict Pgp inhibition are of great interest. A large and accurate literature collection yielded more than 1200 structures; a model was then constructed using various molecular interaction field-based technologies, considering pharmacophoric features and those physicochemical properties related to membrane partitioning. High accuracy was demonstrated internally with two different validation sets and, moreover, using a number of molecules, for which Pgp inhibition was not experimentally available but was evaluated in-house. All of the validations confirmed the robustness of the model and its suitability to help medicinal chemists in drug discovery. The information derived from the model was rationalized as a pharmacophore for competitive Pgp inhibition.

Lipid composition effect on permeability across PAMPA

The parallel artificial membrane permeability assay (PAMPA) system has promise to rapidly screen drug candidate passive permeability, but has been poorly described in terms of its lipid membrane structure and function. The objective was to investigate the role of PAMPA lipid composition on the permeability of five model compounds. PAMPA was used and employed individual phospholipids that varied in phosphate head group and acyl chain unsaturation. Transport of benzoic acid, taurocholic acid, metoprolol, sucrose, and mannitol was measured. Membrane fluidity was assessed by 1,3-diphenylhexatriene fluorescence anisotropy. Results indicate that compound permeability across PAMPA differed in their sensitivity to membrane lipid composition, where compounds with appreciable permeability (i.e. at least 0.2 x 10(-6)cm/s) were possibly sensitive to membrane fluidity and apparent ion pair effects. Benzoic acid permeability ranged 51-fold across membrane types, suggesting acyl chain effect on membrane fluidity. Mannitol, sucrose, and taurocholic acid permeabilities were low and independent of lipid composition. Metoprolol permeability ranged 17-fold and exhibited a markedly high permeability across 1,2-dioleoyl-sn-glycero-3-[phospho-L-serine] due to apparent ion pair-facilitated transport. Compound permeability was lowest across the phosphatidylcholines, which is consistent with phosphatidylcholine exhibiting relatively high membrane rigidity. In contrast to results from phosphatidylethanolamines and phosphatidylserines, acyl chain unsaturation had no effect on permeability across phosphatidylcholines. In conclusion, while much remains unknown about PAMPA structure and subsequent PAMPA permeability, results here from five solutes suggest that, for solutes with appreciable permeability, lipid composition modulated drug permeability through possible membrane fluidity and apparent ion pair influences.

Ion pair-mediated transport of metoprolol across a three lipid-component PAMPA system

Parallel Artificial Membrane Permeability Assay (PAMPA) is a method to screen drug candidates for membrane permeability. The objective was to characterize the transport of a model weak base, metoprolol, across a three lipid-component PAMPA system (denoted A-PAMPA, for anionic-PAMPA) and challenge ion pairing as a mechanism for metoprolol transport. A-PAMPA was designed to mimic the lipid composition of the enterocyte's plasma membrane and included 1,2-dioleoyl-sn-glycero-3-[phospho-l-serine] (PS18:1) as an anionic lipid-component. Metoprolol flux was measured across A-PAMPA, as well as across three other PAMPA systems. Permeability studies were conducted under various conditions, with varying pH, ionic strength, and presence/absence of competing cations. Permeabilities of mannitol and benzoic acid, as model neutral and anionic solutes, were also measured. PAMPA membrane fluidity was inferred from anisotropy measurements in liposomes. Ion pairing between metoprolol and PS18:1 was assessed via NMR. Metoprolol transport across A-PAMPA was dominated by an ion pair-mediated mechanism (i.e. metoprolol-PS18:1 complex), rather than a membrane fluidity-mediated mechanism. Compared to other PAMPA systems, metoprolol permeability across A-PAMPA and PS18:1 was high. Permeability and anisotropy values suggested PS18:1 selectively facilitated metoprolol transport, while neutral lipid did not. Additional studies supporting ion pairing of metoprolol across A-PAMPA showed that a) metoprolol transport was self-inhibited across A-PAMPA but not across neutral lipid PAMPA; b) competing cations reduced metoprolol permeability across A-PAMPA but not across neutral lipid PAMPA; and c) NMR spectrum of a mixture of metoprolol and PS18:1 showed a broadening of some metoprolol peaks, presumably due to metoprolol interaction with anionic lipid. Metoprolol transport across a three lipid-component PAMPA system that contained anionic lipid was facilitated by apparent ion pairing.

Strategies to assess the drug interaction potential in translational medicine

Translational medicine is the drug development phase in which preclinical and clinical applied research is conducted to aid dose and disease selection with great financial impact. Thus, during this phase, early discontinuation of a drug that will later fail due to drug interactions is a must for a proper resource allocation. It is not only important to identify a potential interaction, but also to be able to differentiate between detectable interactions and clinically relevant interactions. Due to the scientific advancement, the prediction of drug interactions during translational medicine has shifted from empirical/observational to rational based. These investigations are thus in line with the FDA's Critical Path Initiative and are facilitated by the availability of mature technologies and by current European and US guidelines for both in vitro and in vivo studies. Because drug interactions must be evaluated in a multidisciplinary fashion, even if these studies are contracted externally, pharmaceutical companies should be directly involved in the conduction of such studies to fully exploit their potential and to allow a better and faster interpretation of the results.

Use of novel prokinetic agents to facilitate return of gastrointestinal motility in adult critically ill patients

PURPOSE OF REVIEW

Intolerance of enteral feeding due to impaired gastrointestinal motility is common in critically ill patients. Strategies to prevent or treat gastrointestinal hypomotility include the use of prokinetic agents. Many currently employed prokinetic agents are associated with serious adverse drug reactions. The novel prokinetic agents - alvimopan, tegaserod, and dexloxiglumide - are reviewed.

RECENT FINDINGS

Alvimopan exerts mixed, but generally favorable, effects on restoration of gastrointestinal motility in patients with postoperative ileus. The observation of increased opioid requirements (without increased pain scores) and associated clinical ramifications requires further study. Tegaserod stimulates the peristaltic reflex and improves motility in multiple sites along the gastrointestinal tract. Its efficacy in improving gastrointestinal hypomotility in the critically ill population has not yet been determined. Furthermore, its use has been associated with the development of ischemic colitis and increased requirement for abdominal/pelvic surgery. Dexloxiglumide may be beneficial for improving gastric emptying in critically ill patients, especially those receiving lipid-enriched enteral feeds.

SUMMARY

Novel prokinetic agents show promise for management of gastrointestinal hypomotility in the critically ill population. However, further study is required before these agents can be recommended for use.

Effect of azole antifungals ketoconazole and fluconazole on the pharmacokinetics of dexloxiglumide

AIMS

Dexloxiglumide is a new CCK(1) receptor antagonist under investigation for treatment of functional gastrointestinal disorders and is metabolized by CYP3A4 and CYP2C9. The objectives of these two separate randomized, two-period, two-treatment crossover studies were to investigate the effects of steady-state ketoconazole, a model CYP3A4 inhibitor (Study 1), and steady-state fluconazole, a model CYP2C9 inhibitor (Study 2), on the pharmacokinetics of dexloxiglumide in healthy subjects.

METHODS

Plasma samples were analysed for dexloxiglumide and its primary metabolites: O-demethyl dexloxiglumide (ODM; Study 1 and 2) and dexloxiglumide carboxylic acid (DCA; Study 2).

RESULTS

Following ketoconazole coadministration, dexloxiglumide C(max) increased by 32% (90% confidence intervals (CI) 112-154), with unchanged ODM C(max); AUC of dexloxiglumide and ODM increased by 36% (90% CI 124-140 and 128-142, respectively). No changes were observed in dexloxiglumide or ODM t((1/2)). Fluconazole coadministration caused a 77% increase (90% CI 154-204) in dexloxiglumide C(max), no change in ODM C(max) and a 32% decrease (90% CI 62-75) in DCA C(max). Fluconazole coadministration resulted in a 2.5-fold increase (90% CI 235-267) in dexloxiglumide AUC, 40% increase (90% CI 136-156) in ODM AUC and an 18% decrease (90% CI 82-94) in DCA AUC. The t((1/2)) of all three analytes increased by approximately 2-fold with fluconazole coadministration (P-value < 0.05).

CONCLUSIONS

Ketoconazole caused a minimal increase while fluconazole caused a moderate increase in dexloxiglumide systemic exposure with no change in the adverse event profile of dexloxiglumide.

Pharmacokinetic Profile of Dexloxiglumide

Dexloxiglumide is a potent and selective cholecystokinin type 1 (CCK1) receptor antagonist currently under development in a variety of diseases affecting the gastrointestinal tract such as gastro-oesophageal reflux disease, irritable bowel syndrome (IBS), functional dyspepsia, constipation and gastric emptying disorders. In female patients with constipation-predominant IBS, clinical efficacy has been demonstrated following administration of dexloxiglumide 200 mg three times daily. Dexloxiglumide is rapidly and extensively absorbed after single oral administration in humans with an absolute bioavailability of 48%. The incomplete bioavailability is due to both incomplete absorption and hepatic first-pass effect. Following multiple-dose administration of 200 mg three times daily, the accumulation is predictable, indicating time-independent pharmacokinetics. In addition, dexloxiglumide pharmacokinetics are dose-independent after both single and repeated oral three-times-daily doses in the dose range 100-400 mg. Dexloxiglumide absorption window extends from the jejunum to the colon and the drug is a substrate and a weak inhibitor of P-glycoprotein and multidrug resistance protein 1. Plasma protein binding of dexloxiglumide is 94-98% and the drug has a moderate to low volume of distribution in humans. Systemic clearance of dexloxiglumide is moderate and cytochrome P450 (CYP) 3A4/5 and CYP2C9 have been implicated in the metabolism of dexloxiglumide to produce O-demethyl dexloxi-glumide. This metabolite is further oxidised to dexloxiglumide carboxylic acid. These two major metabolites (accounting for up to 50% of dexloxiglumide elimination) have been identified. However, in human plasma the unchanged drug represents the major (up to 91%) component of the metabolic profile. The parent drug is believed to be the major contributor to the efficacy of the compound, since its major metabolites are pharmacologically inactive. In addition, the drug is a single isomer chiral drug (eutomer) that does not undergo chiral inversion into its pharmacologically inactive enantiomer (distomer). After oral administration of (14)C-dexloxiglumide, radioactivity is mainly excreted in bile and in faeces (74% of dose) with much lower excretion in urine (20% of dose). Renal excretion of unchanged dexloxiglumide is low (7% of dose in urine and faeces, 1% of dose in urine) and is dose-independent in the dose range 100-400 mg. As the kidney is a minor contributor to the elimination of dexloxiglumide and/or its metabolites in humans, the pharmacokinetics of the drug should not be affected in patients with renal insufficiency. The pharmacokinetics of dexloxiglumide are also not affected by age, sex and administration with a high-fat breakfast. Mild and moderate liver impairment do not affect the pharmacokinetics of dexloxiglumide but severe liver impairment causes increases in systemic exposure to dexloxiglumide and O-demethyl dexloxiglumide. Thus, the drug should be prescribed with caution in patients with severe hepatic impairment even though no dose adjustment is warranted. The results of different drug interaction studies have indicated that no clinically relevant metabolic and concomitant drug-drug interactions are expected during the clinical use of dexloxiglumide.