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Du Y, Zhang Y, Yang Z, Li Y, Wang X, Li Z, Ren L, Li Y. Artificial Neural Network Analysis of Determinants of Tacrolimus Pharmacokinetics in Liver Transplant Recipients. Ann Pharmacother 2024; 58:469-479. [PMID: 37559252 DOI: 10.1177/10600280231190943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND The efficacy and toxicity of tacrolimus are closely related to its trough blood concentrations. Identifying the influencing factors of pharmacokinetics of tacrolimus in the early postoperative period is conducive to the optimization of the individualized tacrolimus administration protocol and to help liver transplant (LT) recipients achieve the target blood concentrations. OBJECTIVE This study aimed to develop an artificial neural network (ANN) for predicting the blood concentration of tacrolimus soon after liver transplantation and for identifying determinants of the concentration based on Shapley additive explanation (SHAP). METHODS In this retrospective study, we enrolled 31 recipients who were first treated with liver transplantation from the Department of Liver Transplantation and Hepatic Surgery, the First Affiliated Hospital of Shandong First Medical University (Shandong Provincial Qianfoshan Hospital) from November 2020 to May 2021. The basic information, biochemical indexes, use of concomitant drugs, and genetic factors of organ donors and recipients were used for the ANN model inputs, and the output was the steady-state trough concentration (C0) of tacrolimus after oral administration in LT recipients. The ANN model was established to predict C0 of tacrolimus, SHAP was applied to the trained model, and the SHAP value of each input was calculated to analyze quantitatively the influencing factors for the output C0. RESULTS A back-propagation ANN model with 3 hidden layers was established using deep learning. The mean prediction error was 0.27 ± 0.75 ng/mL; mean absolute error, 0.60 ± 0.52 ng/mL; correlation coefficient between predicted and actual C0 values, 0.9677; and absolute prediction error of all blood concentrations obtained by the ANN model, ≤3.0 ng/mL. The results indicated that the following factors had the most significant effect on C0: age, daily drug dose, genotype at CYP3A5 polymorphism rs776746 in both recipient and donor, and concomitant use of caspofungin. The predicted C0 value of tacrolimus in LT recipients increased in a dose-dependent manner when the daily dose exceeded 3 mg, whereas it decreased with age when LT recipients were older than 48 years. The predicted C0 was higher when recipients and donors had the genotype CYP3A5*3*3 than when they had the genotype CYP3A5*1. The predicted C0 value also increased with the use of caspofungin or Wuzhi capsule. CONCLUSION AND RELEVANCE The established ANN model can be used to predict the C0 value of tacrolimus in LT recipients with high accuracy and good predictive ability, serving as a reference for personalized treatment in the early stage after liver transplantation.
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Affiliation(s)
- Yue Du
- Clinical Pharmacy, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
- Department of Pharmacy, Zibo Central Hospital, Zibo, China
| | - Yundi Zhang
- School of Pharmaceutical Sciences, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Zhiyan Yang
- Clinical Pharmacy, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yue Li
- Clinical Pharmacy, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Xinyu Wang
- School of Pharmaceutical Sciences, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Ziqiang Li
- Department of Liver Transplantation and Hepatic Surgery, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Lei Ren
- Department of Liver Transplantation and Hepatic Surgery, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yan Li
- Clinical Pharmacy, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
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Ganesh P, Suresh V, Narasimhan MK, Sabarathinam S. A narrative review on Naringin and Naringenin as a possible bioenhancer in various drug-delivery formulations. Ther Deliv 2023; 14:763-774. [PMID: 38088094 DOI: 10.4155/tde-2023-0086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
Naringenin belongs to the flavanones and is mainly found in fruits (grapefruit and oranges) and vegetables. Naringenin exhibits lipid-lowering and insulin-like characteristics and is used to treat osteoporosis, cancer and cardiovascular disorders. Their incorporation into drug formulations offers several advantages, including enhanced solubility, improved bioavailability and targeted delivery. Naringin-based formulations are beneficial in cancer, for example controlling breast and prostate cancer by inhibition of CYP19. Naringin suppresses the PI3K/AKT signalling pathway, it triggers autophagy, which effectively halts the proliferation of gastric cancer cells. Naringin and naringenin co-administration or pre-administration has enhanced the target drug's potency and produced a synergistic effect. This published study demonstrates the potential applications of Naringin and Naringenin as recognized bio-enhancers.
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Affiliation(s)
- Pradeepti Ganesh
- Department of Genetic Engineering, College of Engineering & Technology, SRM Institute of Science & Technology, Kattankulathur, Chennai, Tamil Nadu-603203, India
| | - Vanishree Suresh
- Department of Genetic Engineering, College of Engineering & Technology, SRM Institute of Science & Technology, Kattankulathur, Chennai, Tamil Nadu-603203, India
| | - Manoj Kumar Narasimhan
- Department of Genetic Engineering, College of Engineering & Technology, SRM Institute of Science & Technology, Kattankulathur, Chennai, Tamil Nadu-603203, India
| | - Sarvesh Sabarathinam
- Drug Testing Laboratory, Interdisciplinary Institute of Indian system of Medicine (IIISM), SRM Institute of Science & Technology, Kattankulathur, Chennai, Tamil Nadu-603203, India
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Henkel L, Jehn U, Thölking G, Reuter S. Tacrolimus-why pharmacokinetics matter in the clinic. FRONTIERS IN TRANSPLANTATION 2023; 2:1160752. [PMID: 38993881 PMCID: PMC11235362 DOI: 10.3389/frtra.2023.1160752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/07/2023] [Indexed: 07/13/2024]
Abstract
The calcineurin inhibitor (CNI) Tacrolimus (Tac) is the most prescribed immunosuppressant drug after solid organ transplantation. After renal transplantation (RTx) approximately 95% of recipients are discharged with a Tac-based immunosuppressive regime. Despite the high immunosuppressive efficacy, its adverse effects, narrow therapeutic window and high intra- and interpatient variability (IPV) in pharmacokinetics require therapeutic drug monitoring (TDM), which makes treatment with Tac a major challenge for physicians. The C/D ratio (full blood trough level normalized by daily dose) is able to classify patients receiving Tac into two major metabolism groups, which were significantly associated with the clinical outcomes of patients after renal or liver transplantation. Therefore, the C/D ratio is a simple but effective tool to identify patients at risk of an unfavorable outcome. This review highlights the challenges of Tac-based immunosuppressive therapy faced by transplant physicians in their daily routine, the underlying causes and pharmacokinetics (including genetics, interactions, and differences between available Tac formulations), and the latest data on potential solutions to optimize treatment of high-risk patients.
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Affiliation(s)
- Lino Henkel
- Department of Medicine D, University of Münster, Münster, Germany
| | - Ulrich Jehn
- Department of Medicine D, University of Münster, Münster, Germany
| | - Gerold Thölking
- Department of Medicine D, University of Münster, Münster, Germany
- Department of Internal Medicine and Nephrology, University Hospital of Münster Marienhospital Steinfurt, Steinfurt, Germany
| | - Stefan Reuter
- Department of Medicine D, University of Münster, Münster, Germany
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Maruyama Y, Maejima Y, Hirabayashi K, Morokawa H, Okura E, Saito S, Nakazawa Y. Factors Affecting Day-to-Day Variations in Tacrolimus Concentration among Children and Young Adults Undergoing Allogeneic Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2023; 29:270.e1-270.e8. [PMID: 36682473 DOI: 10.1016/j.jtct.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/16/2022] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Abstract
Tacrolimus is widely used as prophylaxis for graft-versus-host disease (GVHD) in allogeneic stem cell transplantation (allo-HSCT). It has a narrow therapeutic index range; high tacrolimus concentrations are associated with toxicity, whereas low concentrations are associated with an increased risk of GVHD. Although dose adjustments based on therapeutic drug monitoring are performed, unexpected large variations in tacrolimus concentration are sometimes encountered. The available evidence suggests that the factors affecting tacrolimus concentration are not fully understood. This study was aimed primarily at investigating the factors affecting day-to-day variations in tacrolimus concentration in children and young adults who received continuous tacrolimus infusion after allo-HSCT. The secondary objective was to identify the factors causing large variations (>20%) in tacrolimus concentrations. This retrospective cohort study comprised 123 consecutive pediatric and young adult patients (age <25 years) who received continuous i.v. tacrolimus infusion after allo-HSCT at Shinshu University Hospital, Matsumoto, Japan, between January 2009 and December 2021. To compare day-to-day variations in tacrolimus concentration without consideration of the tacrolimus dose, 2 consecutive days when the tacrolimus dose was not changed were selected from between the first post-allo-HSCT day of a tacrolimus concentration >7 ng/mL and day 28 post-allo-HSCT. Subsequently, information for the subsequent 24 hours was collected along with the tacrolimus concentrations and hematocrit values. Tacrolimus concentration was determined using whole blood samples. Tacrolimus concentrations were significantly higher in patients who received red blood cell concentrate (RCC) transfusions (P < .0001) and methotrexate (P = .0162), patients with persistent fever (P = .0056), and patients with a decline in fever (P = .0003). In contrast, tacrolimus concentrations were significantly lower in patients who received platelet concentrate (PC) transfusions (P < .0001), who redeveloped fever (P = .0261), and who had a replaced tacrolimus administration route set (P = .0008). Variations in tacrolimus concentration were significantly correlated with variations in hematocrit (r = .556; P < .0001). Body weight (P < .0001), RCC transfusion (P < .0001), methotrexate use (P = .0333), persistent fever (P = .0150), and decline in fever (P = .0073) were associated with a sharp increase in tacrolimus concentration. In contrast, body weight (P < .0001), PC transfusion (P = .0025), and replacement of the tacrolimus administration route set (P = .0025) were associated with a sharp decrease in tacrolimus concentration. RCC and PC transfusions, fever, methotrexate administration, and replacement of the tacrolimus administration route set were independent factors affecting day-to-day variations in tacrolimus concentration. In addition to these factors, low body weight was a risk factor for both sharp increases and decreases in tacrolimus concentration. These findings suggest the need for better control of tacrolimus concentration using whole blood samples.
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Affiliation(s)
- Yuta Maruyama
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuya Maejima
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Koichi Hirabayashi
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan.
| | - Hirokazu Morokawa
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Eri Okura
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shoji Saito
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yozo Nakazawa
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
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Song X, Liu F, Gao H, Yan M, Zhang F, Zhao J, Qin Y, Li Y, Zhang Y. Compare the performance of multiple machine learning models in predicting tacrolimus concentration for infant patients with living donor liver transplantation. Pediatr Transplant 2023; 27:e14379. [PMID: 36039686 DOI: 10.1111/petr.14379] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/20/2022] [Accepted: 08/02/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND This study aims to establish multiple ML models and compare their performance in predicting tacrolimus concentration for infant patients who received LDLT within 3 months after transplantation. METHODS Retrospectively collected basic information and relevant biochemical indicators of included infant patients. CMIA was used to determine tacrolimus C0 . PCR was used to determine the donors' and recipients' CYP3A5 genotypes. Multivariate stepwise regression analysis and stepwise elimination covariates were used for covariates selection. Thirteen machine learning algorithms were applied for the development of prediction models. APE, the ratio of the APE ≤3 ng ml-1 and ideal rate (the proportion of the predicted value with a relative error of 30% or less) were used to evaluate the predictive performance of the model. RESULTS A total of 163 infant patients were included in this study. In the case of the optimal combination of covariates, the Ridge model had the lowest APE, 2.01 (0.85, 3.35 ng ml-1 ). The highest ratio of the APE ≤3 ng ml-1 was the LAR model (71.77%). And the Ridge model showed the highest ideal rate (55.05%). For the Ridge model, GRWR was the most important predictor. CONCLUSIONS Compared with other ML models, the Ridge model had good predictive performance and potential clinical application.
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Affiliation(s)
- XueWu Song
- First Central Clinical College of Tianjin Medical University, Tianjin, China
| | - FangHao Liu
- College of Computer Science, Tianjin Key Laboratory of Network and Data Security Technology, Nankai University, Tianjin, China
| | - HuiEr Gao
- Department of Pharmacy, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - MeiLing Yan
- Department of Pharmacy, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - FeiYu Zhang
- First Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Jia Zhao
- First Central Clinical College of Tianjin Medical University, Tianjin, China
| | - YinPeng Qin
- Department of Pharmacy, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Yue Li
- College of Computer Science, KLMDASR, Key Laboratory for Medical Data Analysis and Statistical Research, Nankai University, Tianjin, China
| | - Yi Zhang
- Department of Pharmacy, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
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Karwasra R, Ahmad S, Singh S. Potential profound fluctuation in tacrolimus concentration on consumption of pomegranate rind extract: A Pharmacokinetic Experiment. Front Pharmacol 2023; 14:1140706. [PMID: 37153790 PMCID: PMC10154516 DOI: 10.3389/fphar.2023.1140706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/13/2023] [Indexed: 05/10/2023] Open
Abstract
Background: Presently, varied case reports demonstrated an increase or decrease in blood concentration of diverse conventional drugs, often co-administered with edible fruits, spices, or vegetables. The overarching aim of this research is to elucidate the fluctuations in tacrolimus (TAC) blood concentration on the consumption of pomegranate rind extract (PRE). Methods: A pharmacokinetic (PK) study was conducted with two groups, vis-a-vis PRE + TAC (3 mg/kg) and TAC (3 mg/kg) alone groups. An experimental study was conducted in three different manners: Single-dose (S) PRE (200 mg/kg), 7-day repetitive (7-R) PRE (200 mg/kg) dosing, and multiple (M) PRE doses (100, 200, 400, and 800 mg/kg). All the blood samples (approximately 300 μl) were drawn at different time intervals, i.e., 30 min, 1, 2, 4, 8, and 12 h after oral administration of TAC (3 mg/kg). The estimation of TAC in rat plasma was done using the hyphenated technique LC-MS/MS where the mass spectrometer used was a triple-stage quadrupole in multiple-reaction monitoring (MRM) mode. Results: The findings depict that in comparison with the TAC (3 mg/kg) alone group with the 7-day repetitive (7-R) PRE (200 mg/kg) dosing, the Cmax was found to be 9.03 ± 1.21 ng/ml; AUC from time zero to infinity (AUC0-∞), 61.91 ± 17.37 ngh/ml, while the TAC (3 mg/kg) + PRE group exhibited an increase in PK parameters of TAC (Cmax 22.48 ± 3.07 ng/ml; AUC0-∞ 153.08 ± 13.24 ng h/ml). The authors further investigated in what manner the PRE affects the PK of TAC in animals. For this, docking studies with major phytoconstituents present in the PRE with CYP3A4 isoenzyme were carried out. Ellagitannins (dock score, -11.64) and punicalagin (dock score, -10.68) were again used for molecular simulation studies with TAC. To validate our findings, a CYP3A4 inhibitory in vitro assay was conducted. Conclusion: Based on the integrated in vivo and in silico studies, we concluded that pomegranate rind extract interacts strongly with CYP isoenzyme and is therefore responsible for the altered PK profile of TAC.
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Affiliation(s)
- Ritu Karwasra
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
- Central Council for Research in Unani Medicine, Ministry of AYUSH, Government of India, New Delhi, India
| | - Sayeed Ahmad
- School of Pharmacognosy and Phytochemistry, Pharmaceutical Education and Research, Jamia Hamdard University, New Delhi, India
| | - Surender Singh
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
- *Correspondence: Surender Singh,
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Miedziaszczyk M, Bajon A, Jakielska E, Primke M, Sikora J, Skowrońska D, Idasiak-Piechocka I. Controversial Interactions of Tacrolimus with Dietary Supplements, Herbs and Food. Pharmaceutics 2022; 14:pharmaceutics14102154. [PMID: 36297591 PMCID: PMC9611668 DOI: 10.3390/pharmaceutics14102154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/04/2022] [Accepted: 10/07/2022] [Indexed: 12/05/2022] Open
Abstract
Tacrolimus is an immunosuppressive calcineurin inhibitor used to prevent rejection in allogeneic organ transplant recipients, such as kidney, liver, heart or lung. It is metabolized in the liver, involving the cytochrome P450 (CYP3A4) isoform CYP3A4, and is characterized by a narrow therapeutic window, dose-dependent toxicity and high inter-individual and intra-individual variability. In view of the abovementioned facts, the aim of the study is to present selected interactions between tacrolimus and the commonly used dietary supplements, herbs and food. The review was based on the available scientific literature found in the PubMed, Scopus and Cochrane databases. An increase in the serum concentration of tacrolimus can be caused by CYP3A4 inhibitors, such as grapefruit, pomelo, clementine, pomegranate, ginger and turmeric, revealing the side effects of this drug, particularly nephrotoxicity. In contrast, CYP3A4 inducers, such as St. John’s Wort, may result in a lack of therapeutic effect by reducing the drug concentration. Additionally, the use of Panax ginseng, green tea, Schisandra sphenanthera and melatonin in patients receiving tacrolimus is highly controversial. Therefore, since alternative medicine constitutes an attractive treatment option for patients, modern healthcare should emphasize the potential interactions between herbal medicines and synthetic drugs. In fact, each drug or herbal supplement should be reported by the patient to the physician (concordance) if it is taken in the course of immunosuppressive therapy, since it may affect the pharmacokinetic and pharmacodynamic parameters of other preparations.
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Affiliation(s)
- Miłosz Miedziaszczyk
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland
- Correspondence:
| | - Aleksander Bajon
- Student’s Scientific Section of Nephrology and Clinical Transplantology, 61-701 Poznan, Poland
| | - Ewelina Jakielska
- Student’s Scientific Section of Nephrology and Clinical Transplantology, 61-701 Poznan, Poland
| | - Marta Primke
- Student’s Scientific Section of Nephrology and Clinical Transplantology, 61-701 Poznan, Poland
| | - Jędrzej Sikora
- Student’s Scientific Section of Nephrology and Clinical Transplantology, 61-701 Poznan, Poland
| | - Dagmara Skowrońska
- Student’s Scientific Section of Nephrology and Clinical Transplantology, 61-701 Poznan, Poland
| | - Ilona Idasiak-Piechocka
- Department of Nephrology, Transplantology and Internal Medicine, Poznan University of Medical Sciences, 60-355 Poznan, Poland
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Yu KW, Li BL, Yuan YS, Liao JM, Li WK, Dong H, Ke PF, Jin X, Chen L, Zhao JJ, Wang H, Cao SW, Chen WY, Huang XZ, Zhao BB, Kang CM. A modified LC-MS/MS method for the detection of whole blood tacrolimus and its clinical value in Chinese kidney transplant patients. Heliyon 2022; 8:e10214. [PMID: 36042743 PMCID: PMC9420483 DOI: 10.1016/j.heliyon.2022.e10214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/12/2022] [Accepted: 08/03/2022] [Indexed: 11/26/2022] Open
Abstract
Background For patients who treated with tacrolimus after kidney transplant, therapeutic drug monitoring is essential to improve their prognosis. However, previous detection methods have limitations, such as the overestimation and unacceptable bias in the immunoassays. Precision medicine has been challenged. The liquid chromatography-tandem mass spectrometry (LC-MS/MS) method is recognized as the gold standard due to its accuracy and specificity, but lack of throughput and complex process limits its clinical application. Therefore, an accurate, simple and high throughput method for tacrolimus monitoring is needed for clinical practice. Methods A modified LC-MS/MS method was introduced and validated. Whole blood samples were prepared by a one-step protein precipitation method. Chromatographic separation was achieved using a Phenomenex Kinetex 2.6 μm XB-C18 2.1 × 50 mm column with a total run time of 3.5 min to avoid matrix effect. An electrospray ionization source (ESI) was used in positive ion multiple reaction monitoring (MRM) mode for mass spectrometric detection. In order to protect the mass spectrometer, only part of the sample after LC separation was allowed to enter the mass spectrum, through a two HPLC systems coupled one mass spectrometry design. In this way, the instrument throughput is also improved and realizing the detection of 2 samples within 3.5 min and carried out a shorter analyzing time for each sample of 1.75 min. Additionally, we calculated tacrolimus-intrapatient variant (Tac-IPV) based on this modified method and assessed the prognostic value of Tac-IPV in Chinese kidney transplant patients. Results The LC-MS/MS was modified by streamlining the procedure and increasing the throughput. The method proved to be accurate and reproducible with all performance parameters suitably meeting the clinical requirements over a calibration ranged from 0.37 to 42.90 ng/mL. Parameters such as linearity, limit of quantification (LoQ) and dilution integrity were validated with a clinical reportable range from 0.37 to 343.20 ng/mL, which was particularly useful for high drug concentrations patients (rare but very serious). Both cross-contamination and matrix effects were negligible. Clinical data of 83 patients showed that Tac-IPV was associated with poor kidney transplant outcome in Chinese (Hazard Ratio (HR) = 3.96, 4.75; 95% Cl: 1.10–14.21, 1.23–18.36; P < 0.05). Conclusions This modified LC-MS/MS method possessed high throughput and simple sample preparation, allowing it to meet daily clinical needs. At the same time, Tac-IPV based on this modified LC-MS/MS had excellent prognostic value in kidney transplantation. These advantages have great significance for the individualized treatment of Chinese kidney transplant patients and broad application of Tac-IPV.
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Affiliation(s)
- Ke-Wei Yu
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Bing-Ling Li
- Guangzhou KingMed Center for Clinical Laboratory Co., Ltd., KingMed College of Laboratory Medical of Guangzhou Medical University, Guangzhou, Guangdong 510120, China
| | - Ying-Shi Yuan
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Jia-Min Liao
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Wei-Kang Li
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Heng Dong
- Guangzhou KingMed Center for Clinical Laboratory Co., Ltd., KingMed College of Laboratory Medical of Guangzhou Medical University, Guangzhou, Guangdong 510120, China
| | - Pei-Feng Ke
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Xing Jin
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Lu Chen
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Jing-Jing Zhao
- Department of Laboratory Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Heng Wang
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Shun-Wang Cao
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Wei-Ye Chen
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Xian-Zhang Huang
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China.,Department of Laboratory Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong 510120, China
| | - Bei-Bei Zhao
- Guangzhou KingMed Center for Clinical Laboratory Co., Ltd., KingMed College of Laboratory Medical of Guangzhou Medical University, Guangzhou, Guangdong 510120, China
| | - Chun-Min Kang
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China.,Department of Laboratory Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong 510120, China
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Umemura K, Katada Y, Nakagawa S, Sugimoto M, Matsumura K, Yonezawa A, Nagao M, Ohsumi A, Date H, Terada T. Improved absorption of itraconazole tablet by co-administration with lemon beverages in a lung transplant recipient: A case report. J Infect Chemother 2022; 28:1203-1207. [PMID: 35534338 DOI: 10.1016/j.jiac.2022.04.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/07/2022] [Accepted: 04/28/2022] [Indexed: 11/19/2022]
Abstract
After lung transplantation, itraconazole (ITCZ) is used as a prophylaxis for aspergillosis. ITCZ is a weak base with high lipophilicity, and the dissolution and absorption of ITCZ tablets and capsules are pH dependent. Therefore, ITCZ may not achieve sufficient serum concentrations in patients with higher gastric pH because of its poor bioavailability. We report a case of a woman in fifties with post-COVID-19 respiratory failure who successfully underwent lung transplantation, followed by improved bioavailability of ITCZ tablets when given with acidic lemon beverages. The patient was initially administered ITCZ oral solution; this was discontinued because of its unpleasant taste, nausea, and vomiting. The ITCZ oral solution was replaced with ITCZ tablets 78 days after transplantation; however, serum concentrations of ITCZ and hydroxy-ITCZ were below the detection limit (100 ng/mL). We co-administered ITCZ tablets with commercially available lemon beverages. Subsequently, serum concentrations of ITCZ and hydroxy-ITCZ increased to 341 and 673 ng/mL, respectively, on the 125th day after transplantation. Infection with fungi, including Aspergillus spp., was not observed in this case. The patient had no adverse events such as gastric ulcer or hyperglycemia. These results suggest that the co-administration of lemon beverages and ITCZ tablets may help achieve better absorption of ITCZ in patients taking acid suppressants.
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Affiliation(s)
- Keisuke Umemura
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yoshiki Katada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan; Department of Infection Control and Prevention, Kyoto University Hospital, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shunsaku Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Mitsuhiro Sugimoto
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan; Department of Infection Control and Prevention, Kyoto University Hospital, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Katsuyuki Matsumura
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Miki Nagao
- Department of Infection Control and Prevention, Kyoto University Hospital, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan; Department of Clinical Laboratory Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Akihiro Ohsumi
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
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10
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Scherf-Clavel O. Drug-Drug Interactions With Over-The-Counter Medicines: Mind the Unprescribed. Ther Drug Monit 2022; 44:253-274. [PMID: 34469416 DOI: 10.1097/ftd.0000000000000924] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND This review provides a summary of the currently available clinical data on drug-drug interactions (DDIs) involving over-the-counter (OTC) medicines. It aims to educate and increase awareness among health care providers and to support decisions in daily practice. METHODS An extensive literature search was performed using bibliographic databases available through PubMed.gov. An initial structured search was performed using the keywords "drug-drug-interaction AND (over-the-counter OR OTC)," without further restrictions except for the language. The initial results were screened for all described DDIs involving OTC drugs, and further information was gathered specifically on these drugs using dedicated database searches and references found in the bibliography from the initial hits. RESULTS From more than 1200 initial hits (1972-June 2021), 408 relevant publications were screened for DDIs involving OTC drugs, leading to 2 major findings: first, certain types of drug regimens are more prone to DDIs or have more serious DDI-related consequences, such as antiretroviral, anti-infective, and oral anticancer therapies. Second, although most DDIs involve OTC drugs as the perpetrators, some prescription drugs (statins or phosphodiesterase-5 inhibitors) that currently have OTC status can be identified as the victims in DDIs. The following groups were identified to be frequently involved in DDIs: nonsteroidal anti-inflammatory drugs, food supplements, antacids, proton-pump inhibitors, H2 antihistamines, laxatives, antidiarrheal drugs, and herbal drugs. CONCLUSIONS The most significant finding was the lack of high-quality evidence for commonly acknowledged interactions. High-quality interaction studies involving different phenotypes in drug metabolism (cytochrome P450) and distribution (transporters) are urgently needed. This should include modern and critical drugs, such as oral anticancer medications and direct oral anticoagulants.
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Affiliation(s)
- Oliver Scherf-Clavel
- Institute for Pharmacy and Food Chemistry, University of Würzburg, Würzburg, Germany
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11
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Cao Y, Xiang Q, Hu Z, Shuai S, Xiong A. Tacrolimus, cyclosporine, and grapefruit: Friends or foes? Transpl Immunol 2022; 72:101584. [DOI: 10.1016/j.trim.2022.101584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/17/2022] [Accepted: 03/17/2022] [Indexed: 10/18/2022]
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12
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BK Polyomavirus Nephropathy in Kidney Transplantation: Balancing Rejection and Infection. Viruses 2021; 13:v13030487. [PMID: 33809472 PMCID: PMC7998398 DOI: 10.3390/v13030487] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/12/2021] [Accepted: 03/14/2021] [Indexed: 12/16/2022] Open
Abstract
BK polyomavirus nephropathy (BKVN) and allograft rejection are two closely-associated diseases on opposite ends of the immune scale in kidney transplant recipients. The principle of balancing the immune system remains the mainstay of therapeutic strategy. While patient outcomes can be improved through screening, risk factors identification, and rapid reduction of immunosuppressants, a lack of standard curative therapy is the primary concern during clinical practice. Additionally, difficulty in pathological differential diagnosis and clinicopathology’s dissociation pose problems for a definite diagnosis. This article discusses the delicate evaluation needed to optimize immunosuppression and reviews recent advances in molecular diagnosis and immunological therapy for BKVN patients. New biomarkers for BKVN diagnosis are under development. For example, measurement of virus-specific T cell level may play a role in steering immunosuppressants. The development of cellular therapy may provide prevention, even a cure, for BKVN, a complex post-transplant complication.
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13
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Qin XL, Li JL, Wang SH, Chen X, Huang M, Bi HC. Co-administration of Wuzhi tablet (Schisandra sphenanthera extract) alters tacrolimus pharmacokinetics in a dose- and time-dependent manner in rats. JOURNAL OF ETHNOPHARMACOLOGY 2020; 263:113233. [PMID: 32768638 DOI: 10.1016/j.jep.2020.113233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 07/22/2020] [Accepted: 07/29/2020] [Indexed: 06/11/2023]
Abstract
ETHNOPHARMACOLOGY RELEVANCE Tacrolimus is a well-known potent but expensive immunosuppressant. We previously clarified the herb-drug interaction between tacrolimus and Wuzhi tablet (WZ), a prescribed drug of ethanol extract of Schisandra sphenanthera, and showed the ideal effect of WZ on maintaining therapeutic level of tacrolimus and reducing the total drug expense. However, WZ possesses a biphasic effect on regulating CYP3A (the major metabolizing enzyme of tacrolimus), which could induce the mRNA and protein expression after long-term treatment while transiently inhibit the activity of CYP3A. In clinic, clinicians are confused about the relationship between the blood concentration of tacrolimus and the dose and the duration of pretreatment of WZ. Therefore, the effects of the pretreatment time and the dose of WZ on the pharmacokinetics of tacrolimus is urgently needed to be clarified to better combine the use of WZ and tacrolimus in clinic. AIM OF THE STUDY AND METHOD This study aimed to investigate the effects of the pretreatment time and the dose of WZ on the pharmacokinetics of tacrolimus in rats. RESULTS AND CONCLUSIONS After pretreated rats with WZ for 0, 0.5, 2, 6, 12 or 24 h, the area under the curve (AUC) of tacrolimus was 2.27 ± 0.59, 1.87 ± 1.14, 2.86 ± 0.64, 1.62 ± 0.70, 1.54 ± 1.06 and 1.12 ± 0.69-fold of that of the tacrolimus alone group, respectively. The ratio of AUC of tacrolimus to that of the co-administration group with 0, 62.5, 125, 250, 500 or 750 mg/kg of WZ was 1.00: 1.07: 1.44: 2.60: 2.32: 2.42, respectively. These findings suggested that WZ increased tacrolimus AUC in a pretreatment time- and dose-dependent manner. In line with the in vivo findings, WZ extract inhibited CYP3A activity in a pre-treatment time- and concentration-dependent manner in human liver microsomes. In conclusion, the pharmacokinetics of tacrolimus was significantly affected by the pretreatment time and the dose of WZ. Oral pretreatment with WZ for 0-2 h or co-dosing of 250 mg/kg of WZ most significantly increased the blood concentration of tacrolimus. These findings would be helpful for guiding the reasonable use of WZ and tacrolimus in clinic.
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Affiliation(s)
- Xiao-Ling Qin
- Guangdong Food and Drug Vocational College, Guangzhou, PR China
| | - Jia-Li Li
- School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
| | - Si-Han Wang
- School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China
| | - Xiao Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Min Huang
- School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China.
| | - Hui-Chang Bi
- School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, PR China.
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14
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Kuypers DRJ. Intrapatient Variability of Tacrolimus Exposure in Solid Organ Transplantation: A Novel Marker for Clinical Outcome. Clin Pharmacol Ther 2019; 107:347-358. [PMID: 31449663 DOI: 10.1002/cpt.1618] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 08/14/2019] [Indexed: 12/12/2022]
Abstract
The calcineurin-inhibitor tacrolimus (Tac) provides an acceptable balance between prevention of allograft rejection and drug-related adverse effects, making it the standard of care in all types of solid organ transplantation for the last 2 decades. Recent data have demonstrated that high intrapatient variability (IPV) in Tac predose trough concentrations has deleterious effects on allograft survival. The underlying mechanisms by which a high Tac IPV shortens allograft survival are acute and chronic rejection, donor-specific anti-HLA antibodies, and progressive fibrotic damage to the graft. Modifiable causes of high Tac IPV include medication nonadherence (MNA), drug interactions, nutritional interferences, and concurrent diseases. Recognizing high Tac IPV as an important prognostic risk factor after solid organ transplantation requires understanding of the definitions, the use of correct diagnostic metrics, and methodology. Therapeutic interventions aimed at reducing Tac IPV are targeted on improving MNA, avoiding or adjusting drug interactions, drug dosing assists, and educational support of recipients.
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Affiliation(s)
- Dirk R J Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology and Immunology, Catholic University of Leuven, Leuven, Belgium
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15
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Zhai X, Chen C, Xu X, Ma L, Zhou S, Wang Z, Ma L, Zhao X, Zhou Y, Cui Y. Marked change in blood tacrolimus concentration levels due to grapefruit in a renal transplant patient. J Clin Pharm Ther 2019; 44:819-822. [PMID: 31231823 DOI: 10.1111/jcpt.13002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 03/10/2019] [Accepted: 05/29/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Xingyu Zhai
- Department of Pharmacy Peking University First Hospital Beijing China
- School of Pharmaceutical Sciences Peking University Health Science Center Beijing China
| | - Chaoyang Chen
- Department of Pharmacy Peking University First Hospital Beijing China
| | - Xin Xu
- Department of Urology Peking University First Hospital Beijing China
| | - Lingyue Ma
- Department of Pharmacy Peking University First Hospital Beijing China
| | - Shuang Zhou
- Department of Pharmacy Peking University First Hospital Beijing China
| | - Zhiqi Wang
- Department of Pharmacy Peking University First Hospital Beijing China
- School of Pharmaceutical Sciences Peking University Health Science Center Beijing China
| | - Lingyun Ma
- Department of Pharmacy Peking University First Hospital Beijing China
| | - Xia Zhao
- Department of Pharmacy Peking University First Hospital Beijing China
- School of Pharmaceutical Sciences Peking University Health Science Center Beijing China
| | - Ying Zhou
- Department of Pharmacy Peking University First Hospital Beijing China
- School of Pharmaceutical Sciences Peking University Health Science Center Beijing China
| | - Yimin Cui
- Department of Pharmacy Peking University First Hospital Beijing China
- School of Pharmaceutical Sciences Peking University Health Science Center Beijing China
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16
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Therapeutic Drug Monitoring of Tacrolimus-Personalized Therapy: Second Consensus Report. Ther Drug Monit 2019; 41:261-307. [DOI: 10.1097/ftd.0000000000000640] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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17
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Brunet M, van Gelder T, Åsberg A, Haufroid V, Hesselink DA, Langman L, Lemaitre F, Marquet P, Seger C, Shipkova M, Vinks A, Wallemacq P, Wieland E, Woillard JB, Barten MJ, Budde K, Colom H, Dieterlen MT, Elens L, Johnson-Davis KL, Kunicki PK, MacPhee I, Masuda S, Mathew BS, Millán O, Mizuno T, Moes DJAR, Monchaud C, Noceti O, Pawinski T, Picard N, van Schaik R, Sommerer C, Vethe NT, de Winter B, Christians U, Bergan S. Therapeutic Drug Monitoring of Tacrolimus-Personalized Therapy: Second Consensus Report. Ther Drug Monit 2019. [DOI: 10.1097/ftd.0000000000000640
expr 845143713 + 809233716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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18
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Leino AD, King EC, Jiang W, Vinks AA, Klawitter J, Christians U, Woodle ES, Alloway RR, Rohan JM. Assessment of tacrolimus intrapatient variability in stable adherent transplant recipients: Establishing baseline values. Am J Transplant 2019; 19:1410-1420. [PMID: 30506623 DOI: 10.1111/ajt.15199] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/14/2018] [Accepted: 11/26/2018] [Indexed: 01/25/2023]
Abstract
The purpose of this study was to determine the intrapatient (within the same patient) variability of tacrolimus in adherent patients. Daily tacrolimus trough levels were obtained at home using dried blood spot technology in kidney and liver transplant recipients. Patients were randomized to receive 3 formulations of tacrolimus, each for two 1-week periods. Adherence was monitored by patient diary, pill counts, and use of the Medication Event Monitoring System (MEMS). Variability was quantified as the coefficient of variation (CV). Comparison of CV between groups was by independent t test or one-way ANOVA as appropriate. The population was found to be adherent with a rate of 99.9% with a mean interval between the evening and morning dose of tacrolimus of 11.86 hours. The median CV for the entire population was 15.2% (range 4.8%-110%). There were no differences in CV by allograft type or tacrolimus formulation. The multivariate analysis did not identify any demographic characteristics associated with a CV > 30%. In a highly adherent population, tacrolimus did not display high intrapatient variability. Given the association between IPV and poor allograft outcomes, future studies are needed to quantitate the influence of adherence and establish target IPV goals.
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Affiliation(s)
- Abbie D Leino
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Eileen C King
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Wenlei Jiang
- Office of Research and Standards, Office of Generic Drugs, Center for Drug Evaluation and Research, U.S. Food & Drug Administration, Silver Spring, Maryland
| | - Alexander A Vinks
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jost Klawitter
- iC42 Clinical Research and Development, University of Colorado, Aurora, Colorado
| | - Uwe Christians
- iC42 Clinical Research and Development, University of Colorado, Aurora, Colorado
| | - E Steve Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rita R Alloway
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jennifer M Rohan
- Division of Hematology and Oncology, Children's Hospital of Richmond, Richmond, Virginia
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19
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Gjestad C, Hole K, Haslemo T, Diczfalusy U, Molden E. Effect of Grapefruit Juice Intake on Serum Level of the Endogenous CYP3A4 Metabolite 4β-Hydroxycholesterol-an Interaction Study in Healthy Volunteers. AAPS JOURNAL 2019; 21:58. [PMID: 31020430 DOI: 10.1208/s12248-019-0330-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/05/2019] [Indexed: 12/20/2022]
Abstract
4β-Hydroxycholesterol (4βOHC) is an endogenous CYP3A4 metabolite. However, it is unclear whether circulating levels of 4βOHC may reflect hepatic CYP3A4 activity or both hepatic and intestinal enzyme activity. The aim of this study was to investigate the effect of grapefruit juice, regarded to be a selective intestinal CYP3A4 inhibitor, on serum 4βOHC levels in healthy volunteers. The participants (n = 22) consumed grapefruit juice twice daily for 3 weeks followed by a 2-week washout period. Blood samples for measurements of 4βOHC and the non-CYP3A4-derived oxysterols 24-hydroxycholesterol (24OHC) and 27-hydroxycholesterol (27OHC), as well as lathosterol and total cholesterol, were drawn on days 0, 7, 21, and 35. Median individual changes (ratios) in cholesterol-corrected 4βOHC levels from baseline to weeks 1, 3, and 5 were 0.94 (P = 0.2), 0.98 (P = 0.3), and 0.97 (P = 0.9), respectively. In comparison, median changes (ratios) in cholesterol-corrected levels of 24OHC at the same points were 1.01 (P = 0.6), 0.98 (P = 0.3), and 0.99 (P = 0.5), and of 27OHC 1.01 (P = 0.8), 0.97 (P = 0.5), and 0.99 (P = 0.2). Surprisingly, serum concentration of cholesterol was significantly reduced by approximately 5% after 1 week (P = 0.03), while median cholesterol-corrected levels of lathosterol increased significantly and persistently by approximately 15% during the whole 5-week period (P < 0.04). In conclusion, the present findings suggest that intestinal CYP3A4 is not relevant for the overall formation of 4βOHC in healthy volunteers. The fact that grapefruit juice altered cholesterol homeostasis should be further investigated.
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Affiliation(s)
- Caroline Gjestad
- Center for Psychopharmacology, Diakonhjemmet Hospital, PO Box 85, Vinderen, N-0319, Oslo, Norway.
| | - Kristine Hole
- Center for Psychopharmacology, Diakonhjemmet Hospital, PO Box 85, Vinderen, N-0319, Oslo, Norway
| | - Tore Haslemo
- Center for Psychopharmacology, Diakonhjemmet Hospital, PO Box 85, Vinderen, N-0319, Oslo, Norway
| | - Ulf Diczfalusy
- Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Sweden
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, PO Box 85, Vinderen, N-0319, Oslo, Norway.,Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway
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20
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Hohmann N, Mikus G, Haefeli WE, Schwenger V, Gattuso G, Barreca D, Weiss J. A follow-up report on potential drug interactions with clementines: Two single case experiments show no effect on CYP3A-dependent midazolam clearance. Eur J Pharm Sci 2019; 133:54-58. [PMID: 30905614 DOI: 10.1016/j.ejps.2019.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/05/2019] [Accepted: 03/15/2019] [Indexed: 11/29/2022]
Abstract
We have previously demonstrated that clementines have in vitro drug interaction potential. To assess the clinical relevance of clementine-drug interaction, two single case experiments with repetitive phenotyping of CYP3A activity were conducted. Although an increment of 43% in the estimated midazolam clearance (eCLmet) was observed during the first experiment in a renal transplant patient on tacrolimus after 4-d consumption of clementines (1 kg/d), and an increment of +89% of eCLmet was observed during chronic consumption of clementine juice in a healthy male volunteer, these changes lie within the range of intra-individual variability. Therefore one cannot assure a potential drug interaction due to the clementines, but prescribers should be cautious unless further data emerges. In contrast to the juice used for the in vitro assay comprising several flavonoids, this juice only contained hesperidin and narirutin indicating that the drug interactions potential of clementines might depend on the composition varying from batch to batch.
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Affiliation(s)
- Nicolas Hohmann
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Walter Emil Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Vedat Schwenger
- Department of Endocrinology, Metabolism and Clinical Chemistry, Section of Nephrology, University of Heidelberg, Im Neuenheimer Feld 162, 69120 Heidelberg, Germany
| | - Giuseppe Gattuso
- Dipartimento di Scienze Chimiche, Biologiche, Farmaceutiche ed Ambientali, Università di Messina, Viale F. Stagno d'Alcontres 31, 98166 Messina, Italy
| | - Davide Barreca
- Dipartimento di Scienze Chimiche, Biologiche, Farmaceutiche ed Ambientali, Università di Messina, Viale F. Stagno d'Alcontres 31, 98166 Messina, Italy
| | - Johanna Weiss
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany.
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Tacrolimus Variability: A Cause of Donor-Specific Anti-HLA Antibody Formation in Children. Eur J Drug Metab Pharmacokinet 2019; 44:539-548. [DOI: 10.1007/s13318-019-00544-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 01/23/2019] [Indexed: 10/27/2022]
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22
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Li J, Chen S, Qin X, Fu Q, Bi H, Zhang Y, Wang X, Liu L, Wang C, Huang M. Wuzhi Tablet (Schisandra sphenanthera Extract) Is a Promising Tacrolimus-Sparing Agent for Renal Transplant Recipients Who Are CYP3A5 Expressers: a Two-Phase Prospective Study. Drug Metab Dispos 2017; 45:1114-1119. [DOI: 10.1124/dmd.117.076737] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 08/17/2017] [Indexed: 01/06/2023] Open
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23
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Masuda M, Watanabe S, Tanaka M, Tanaka A, Araki H. Screening of furanocoumarin derivatives as cytochrome P450 3A4 inhibitors in citrus. J Clin Pharm Ther 2017; 43:15-20. [DOI: 10.1111/jcpt.12595] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 06/23/2017] [Indexed: 11/28/2022]
Affiliation(s)
- M. Masuda
- Division of Pharmacy; Ehime University Hospital; Toon Ehime Japan
| | - S. Watanabe
- Division of Pharmacy; Ehime University Hospital; Toon Ehime Japan
| | - M. Tanaka
- Division of Pharmacy; Ehime University Hospital; Toon Ehime Japan
| | - A. Tanaka
- Division of Pharmacy; Ehime University Hospital; Toon Ehime Japan
| | - H. Araki
- Division of Pharmacy; Ehime University Hospital; Toon Ehime Japan
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A Retrospective Study on Mycophenolic Acid Drug Interactions: Effect of Prednisone, Sirolimus, and Tacrolimus With MPA. Ther Drug Monit 2017; 39:220-228. [DOI: 10.1097/ftd.0000000000000403] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Tacrolimus Blood Level Fluctuation Predisposes to Coexisting BK Virus Nephropathy and Acute Allograft Rejection. Sci Rep 2017; 7:1986. [PMID: 28512328 PMCID: PMC5434044 DOI: 10.1038/s41598-017-02140-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 04/06/2017] [Indexed: 12/18/2022] Open
Abstract
BK virus nephropathy (BKVN) and allograft rejection are two distinct disease entities which occur at opposite ends of the immune spectrum. However, they coexist in renal transplant recipients. Predisposing factors for this coexistence remain elusive. We identified nine biopsy-proven BKVN patients with coexisting acute rejection, and 21 patients with BKVN alone. We retrospectively analyzed the dosage and blood concentrations of immunosuppressants during the 3-month period prior to the renal biopsy between the two patient groups. Compared to the BKVN alone group, renal function was noticeably worse in the coexistence group (p = 0.030). Regarding the dose and average drug level of immunosuppressants, there was no difference between the two groups. Interestingly, the coefficient of variance of tacrolimus trough blood level was noticeably higher during the 3-month period prior to the renal biopsy in the coexistence group (p = 0.010). Our novel findings suggest that a higher variability of tacrolimus trough level may be associated with the coexistence of BKVN and acute rejection. Since the prognosis is poor and the treatment is challenging in patients with coexisting BKVN and acute rejection, transplant clinicians should strive to avoid fluctuations in immunosuppressant drug levels in patients with either one of these two disease entities.
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Practical Recommendations for Long-term Management of Modifiable Risks in Kidney and Liver Transplant Recipients: A Guidance Report and Clinical Checklist by the Consensus on Managing Modifiable Risk in Transplantation (COMMIT) Group. Transplantation 2017; 101:S1-S56. [PMID: 28328734 DOI: 10.1097/tp.0000000000001651] [Citation(s) in RCA: 181] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Short-term patient and graft outcomes continue to improve after kidney and liver transplantation, with 1-year survival rates over 80%; however, improving longer-term outcomes remains a challenge. Improving the function of grafts and health of recipients would not only enhance quality and length of life, but would also reduce the need for retransplantation, and thus increase the number of organs available for transplant. The clinical transplant community needs to identify and manage those patient modifiable factors, to decrease the risk of graft failure, and improve longer-term outcomes.COMMIT was formed in 2015 and is composed of 20 leading kidney and liver transplant specialists from 9 countries across Europe. The group's remit is to provide expert guidance for the long-term management of kidney and liver transplant patients, with the aim of improving outcomes by minimizing modifiable risks associated with poor graft and patient survival posttransplant.The objective of this supplement is to provide specific, practical recommendations, through the discussion of current evidence and best practice, for the management of modifiable risks in those kidney and liver transplant patients who have survived the first postoperative year. In addition, the provision of a checklist increases the clinical utility and accessibility of these recommendations, by offering a systematic and efficient way to implement screening and monitoring of modifiable risks in the clinical setting.
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27
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Nayeri A, Wu S, Adams E, Tanner C, Meshman J, Saini I, Reid W. Acute Calcineurin Inhibitor Nephrotoxicity Secondary to Turmeric Intake: A Case Report. Transplant Proc 2017; 49:198-200. [PMID: 28104136 DOI: 10.1016/j.transproceed.2016.11.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 11/16/2016] [Indexed: 11/16/2022]
Abstract
Tacrolimus, also known as FK-506, is a potent immunosuppressant agent with a host of drug-drug and food-drug interactions. We present the first case of a probable food-drug interaction between the herb turmeric and tacrolimus leading to acute calcineurin inhibitor nephrotoxicity. A 56-year-old man with a history of orthotopic liver transplantation presented to the emergency department from the clinic with worsening edema in the setting of an elevated creatinine level of 4.2 mg/dL. Before the current presentation, the patient had been recently discharged on a previously tolerated low-dose regimen of tacrolimus with a whole-blood tacrolimus level within the desired range. Tacrolimus level on the day of re-hospitalization was elevated to 29.9 ng/mL in the absence of any changes to the patient's medication regimen. On further prompting, the patient identified recent high-dose intake of turmeric with his food. Tacrolimus was held from the patient's medication regimen, and he was discharged on hospital day 4 with objective evidence of improving renal function. Our report builds on the previous studies that described the effects of turmeric or its active ingredient on the pharmacokinetics of tacrolimus. The appropriate reconciliation of herbal agents such as turmeric can be worthwhile in patients with unexplained changes in tacrolimus levels.
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Affiliation(s)
- A Nayeri
- Department of Medicine, University of California, Los Angeles, California.
| | - S Wu
- Department of Medicine, University of California, Los Angeles, California
| | - E Adams
- Department of Medicine, University of California, Los Angeles, California
| | - C Tanner
- Department of Medicine, University of California, Los Angeles, California
| | - J Meshman
- Department of Medicine, University of California, Los Angeles, California
| | - I Saini
- Department of Medicine, University of California, Los Angeles, California
| | - W Reid
- Department of Medicine, University of California, Los Angeles, California
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Chen WY, Lee CY, Lin PY, Hsieh CE, Ko CJ, Lin KH, Lin CC, Ming YZ, Chen YL. Betel Nut Chewing Is Associated With Reduced Tacrolimus Concentration in Taiwanese Liver Transplant Recipients. Transplant Proc 2017; 49:326-329. [PMID: 28219593 DOI: 10.1016/j.transproceed.2016.11.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/20/2016] [Accepted: 11/16/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE Studies have shown that arecoline, the major alkaloid component of betel nuts, alters the activity of enzymes in the cytochrome P450 (CYP-450) family. Tacrolimus, an immunosuppressant that protects against organ rejection in transplant recipients, not only is mainly metabolized by CYP3A enzymes but also has a narrow therapeutic range. We aimed to investigate whether dose-adjusted blood trough levels of tacrolimus differed over time between betel nut-chewing and non-betel nut-chewing liver transplant recipients. METHODS In this retrospective case-control study, 14 active betel nut-using liver recipients were matched at a 1:2 ratio to 28 non-betel nut-using liver recipients by sex, age, graft source, duration of follow-up after liver transplantation, and estimated glomerular filtration rate. Differences in liver function index, renal function index, and dose-adjusted blood trough levels of tacrolimus over an 18-month period were compared between the 2 groups by using the Generalized Estimating Equation approach. RESULTS Dose-adjusted blood trough levels of tacrolimus tended to be significantly (P = .04) lower in betel nut chewers (mean = 0.81, medium = 0.7, 95% confidence interval [CI] = 0.73 to 0.90) than in nonchewers (mean = 1.12, medium = 0.88, 95% CI = 1.03 to 1.22) during the 18-month study period. However, there was no significant difference in renal and liver function index between the 2 groups. CONCLUSION Liver transplant recipients receiving tacrolimus tend to have lower blood trough levels of the drug over time if they chew betel nuts.
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Affiliation(s)
- W-Y Chen
- Department of Pharmacy, Changhua Christian Hospital, Changhua, Taiwan
| | - C-Y Lee
- Department of Pharmacy, Changhua Christian Hospital, Changhua, Taiwan
| | - P-Y Lin
- Transplant Medicine & Surgery Research Centre, Changhua Christian Hospital, Changhua, Taiwan
| | - C-E Hsieh
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - C-J Ko
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - K-H Lin
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - C-C Lin
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Y-Z Ming
- Transplantation Center, Third Xiangya Hospital of Central South University, Changsha, China
| | - Y-L Chen
- Department of General Surgery, Changhua Christian Hospital, Changhua, Taiwan; Transplant Medicine & Surgery Research Centre, Changhua Christian Hospital, Changhua, Taiwan; Transplantation Center, Third Xiangya Hospital of Central South University, Changsha, China; School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Theile D, Hohmann N, Kiemel D, Gattuso G, Barreca D, Mikus G, Haefeli WE, Schwenger V, Weiss J. Clementine juice has the potential for drug interactions – In vitro comparison with grapefruit and mandarin juice. Eur J Pharm Sci 2017; 97:247-256. [DOI: 10.1016/j.ejps.2016.11.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 11/07/2016] [Accepted: 11/19/2016] [Indexed: 02/07/2023]
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Dave AA, Samuel J. Suspected Interaction of Cranberry Juice Extracts and Tacrolimus Serum Levels: A Case Report. Cureus 2016; 8:e610. [PMID: 27335715 PMCID: PMC4911337 DOI: 10.7759/cureus.610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Cytochrome P450 inhibition through fruit supplement interactions often results in increased serum levels of calcineurin inhibitors, including tacrolimus. Cranberry extract is a supplement often used for the prevention of recurrent urinary tract infections (UTIs), which are common in renal allograft recipients. To our knowledge, a decrease in serum levels of tacrolimus as a result of cranberry extract interaction is unreported. A 40-year-old renal transplant patient taking cranberry extract capsules for her recurrent cystitis presented asymptomatically with low serum levels of tacrolimus. Dose increase had little effect on the level, and cessation of the cranberry extract returned levels to desired range. Cranberry extracts are an adjunctive therapy used in the management of recurrent UTIs. Tacrolimus, an immunosuppressive agent, is metabolized intestinally by isoenzymes of the P450 cytochrome. Cranberry extracts may alter this metabolism and lead to sub-therapeutic serum levels of tacrolimus. This interaction is heretofore unreported. Cranberry extracts should be carefully monitored in allograft recipients due to interactions with serum tacrolimus levels.
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Affiliation(s)
- Atman A Dave
- Medical Education, Saint Luke's Hospital of Kansas City
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31
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Vanhove T, Annaert P, Kuypers DRJ. Clinical determinants of calcineurin inhibitor disposition: a mechanistic review. Drug Metab Rev 2016; 48:88-112. [DOI: 10.3109/03602532.2016.1151037] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Explication of Definitional Description and Empirical Use of Fraction of Orally Administered Drugs Absorbed From the Intestine (F a ) and Intestinal Availability (F g ): Effect of P-glycoprotein and CYP3A on F a and F g. J Pharm Sci 2016; 105:431-442. [DOI: 10.1016/j.xphs.2015.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 11/05/2015] [Accepted: 11/10/2015] [Indexed: 01/13/2023]
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Tsuji H, Ohmura K, Nakashima R, Hashimoto M, Imura Y, Yukawa N, Yoshifuji H, Fujii T, Mimori T. Efficacy and Safety of Grapefruit Juice Intake Accompanying Tacrolimus Treatment in Connective Tissue Disease Patients. Intern Med 2016; 55:1547-52. [PMID: 27301503 DOI: 10.2169/internalmedicine.55.5553] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective It is well known that grapefruit juice (GFJ) elevates the blood tacrolimus (TAC) concentration. We investigated the efficacy and safety of GFJ intake with TAC in cases of connective tissue diseases in which the TAC blood concentration was insufficiently high for clinical improvement, even when 3 mg/day or more of TAC was administered. Methods Seven patients took 200 mL of GFJ every day. The trough levels of the TAC blood concentration were measured before and after GFJ intake and the clinical courses were monitored thereafter. Results First, we surveyed the blood TAC trough levels of 30 recent patients who took 3 mg/day of TAC, and found that 21 patients (70%) did not achieve the minimum target TAC concentration (>5 ng/mL). Seven patients took GFJ due to a lack of efficacy and a relatively low TAC blood concentration. GFJ increased the TAC level from 4.3±2.4 ng/mL to 13.8±6.9 ng/mL (average increase: 3.3-fold). GFJ was also effective in achieving a clinical improvement in most cases without causing any severe adverse events, and it helped to decrease the dosages of glucocorticoid and TAC. In some cases, the blood TAC concentration fluctuated for no apparent reason. Conclusion GFJ intake was effective for the elevation of TAC concentration by approximately three fold and clinical improvement, but special care is required for monitoring its influence on concomitantly used drugs as well as TAC concentration. The addition of GFJ to TAC treatment could be an efficacious treatment option, when the plasma TAC concentration does not reach the minimal target concentration.
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Affiliation(s)
- Hideaki Tsuji
- Department of Rheumatology and Clinical Immunology, Kyoto University Graduate School of Medicine, Japan
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Shuker N, van Gelder T, Hesselink DA. Intra-patient variability in tacrolimus exposure: causes, consequences for clinical management. Transplant Rev (Orlando) 2015; 29:78-84. [PMID: 25687818 DOI: 10.1016/j.trre.2015.01.002] [Citation(s) in RCA: 155] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 12/22/2014] [Accepted: 01/11/2015] [Indexed: 12/18/2022]
Abstract
Tacrolimus (Tac) is widely used for the prevention of rejection after solid organ transplantation. Finding the optimal balance between effective Tac concentrations and toxicity is a challenge and requires therapeutic drug monitoring. In addition to the well-known inter-patient variability, the clinical use of Tac is also complicated by considerable intra-patient variability (IPV) in Tac exposure. Tac IPV is defined as the amount of fluctuation of whole-blood concentrations over a certain period of time during which the Tac dose remains unchanged. A high IPV in Tac exposure has recently been recognized as a strong risk factor for acute rejection and poor long-term kidney transplantation outcome. In addition to non-adherence, several other factors determine the magnitude of the IPV in Tac exposure. Quantification of IPV is easy and can be easily incorporated into everyday clinical practice as a tool for optimizing transplantation outcomes.
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Affiliation(s)
- Nauras Shuker
- Department of Internal Medicine, Division of Nephrology and Renal Transplantation, Erasmus MC, University Medical Center, Rotterdam, the Netherlands; Hospital Pharmacy, Clinical Pharmacology Unit, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.
| | - Teun van Gelder
- Department of Internal Medicine, Division of Nephrology and Renal Transplantation, Erasmus MC, University Medical Center, Rotterdam, the Netherlands; Hospital Pharmacy, Clinical Pharmacology Unit, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology and Renal Transplantation, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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Li CJ, Li L. Tacrolimus in preventing transplant rejection in Chinese patients--optimizing use. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:473-85. [PMID: 25609922 PMCID: PMC4298305 DOI: 10.2147/dddt.s41349] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Tacrolimus is a product of fermentation of Streptomyces, and belongs to the family of calcineurin inhibitors. It is a widely used immunosuppressive drug for preventing solid-organ transplant rejection. Compared to cyclosporine, tacrolimus has greater immunosuppressive potency and a lower incidence of side effects. It has been accepted as first-line treatment after liver and kidney transplantation. Tacrolimus has specific features in Chinese transplant patients; its in vivo pharmacokinetics, treatment regimen, dose and administration, and adverse-effect profile are influenced by multiple factors, such as genetics and the spectrum of primary diseases in the Chinese population. We reviewed the clinical experience of tacrolimus use in Chinese liver- and kidney-transplant patients, including the pharmacology of tacrolimus, the immunosuppressive effects of tacrolimus versus cyclosporine, effects of different factors on tacrolimus metabolism on Chinese patients, personalized medicine, clinical safety profile, and patient satisfaction and adherence. This article provides guidance for the rational and efficient use of tacrolimus in Chinese organ-transplant patients.
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Affiliation(s)
- Chuan-Jiang Li
- Department of Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Liang Li
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, People's Republic of China
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36
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Ainslie GR, Wolf KK, Li Y, Connolly EA, Scarlett YV, Hull JH, Paine MF. Assessment of a candidate marker constituent predictive of a dietary substance-drug interaction: case study with grapefruit juice and CYP3A4 drug substrates. J Pharmacol Exp Ther 2014; 351:576-84. [PMID: 25253884 DOI: 10.1124/jpet.114.216838] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Dietary substances, including herbal products and citrus juices, can perpetrate interactions with conventional medications. Regulatory guidances for dietary substance-drug interaction assessment are lacking. This deficiency is due in part to challenges unique to dietary substances, a lack of requisite human-derived data, and limited jurisdiction. An in vitro-in vivo extrapolation (IVIVE) approach to help address some of these hurdles was evaluated using the exemplar dietary substance grapefruit juice (GFJ), the candidate marker constituent 6',7'-dihydroxybergamottin (DHB), and the purported victim drug loperamide. First, the GFJ-loperamide interaction was assessed in 16 healthy volunteers. Loperamide (16 mg) was administered with 240 ml of water or GFJ; plasma was collected from 0 to 72 hours. Relative to water, GFJ increased the geometric mean loperamide area under the plasma concentration-time curve (AUC) significantly (1.7-fold). Second, the mechanism-based inhibition kinetics for DHB were recovered using human intestinal microsomes and the index CYP3A4 reaction, loperamide N-desmethylation (KI [concentration needed to achieve one-half kinact], 5.0 ± 0.9 µM; kinact [maximum inactivation rate constant], 0.38 ± 0.02 minute(-1)). These parameters were incorporated into a mechanistic static model, which predicted a 1.6-fold increase in loperamide AUC. Third, the successful IVIVE prompted further application to 15 previously reported GFJ-drug interaction studies selected according to predefined criteria. Twelve of the interactions were predicted to within the 25% predefined criterion. Results suggest that DHB could be used to predict the CYP3A4-mediated effect of GFJ. This time- and cost-effective IVIVE approach could be applied to other dietary substance-drug interactions to help prioritize new and existing drugs for more advanced (dynamic) modeling and simulation and clinical assessment.
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Affiliation(s)
- Garrett R Ainslie
- Curriculum in Toxicology (G.R.A., M.F.P.) and Division of Gastroenterology and Hepatology (Y.V.S.), School of Medicine, and UNC Eshelman School of Pharmacy (K.K.W., Y.L., E.A.C., J.H.H.), The University of North Carolina, Chapel Hill, North Carolina; and Experimental and Systems Pharmacology, College of Pharmacy, Washington State University, Spokane, Washington (G.R.A., M.F.P.)
| | - Kristina K Wolf
- Curriculum in Toxicology (G.R.A., M.F.P.) and Division of Gastroenterology and Hepatology (Y.V.S.), School of Medicine, and UNC Eshelman School of Pharmacy (K.K.W., Y.L., E.A.C., J.H.H.), The University of North Carolina, Chapel Hill, North Carolina; and Experimental and Systems Pharmacology, College of Pharmacy, Washington State University, Spokane, Washington (G.R.A., M.F.P.)
| | - Yingxin Li
- Curriculum in Toxicology (G.R.A., M.F.P.) and Division of Gastroenterology and Hepatology (Y.V.S.), School of Medicine, and UNC Eshelman School of Pharmacy (K.K.W., Y.L., E.A.C., J.H.H.), The University of North Carolina, Chapel Hill, North Carolina; and Experimental and Systems Pharmacology, College of Pharmacy, Washington State University, Spokane, Washington (G.R.A., M.F.P.)
| | - Elizabeth A Connolly
- Curriculum in Toxicology (G.R.A., M.F.P.) and Division of Gastroenterology and Hepatology (Y.V.S.), School of Medicine, and UNC Eshelman School of Pharmacy (K.K.W., Y.L., E.A.C., J.H.H.), The University of North Carolina, Chapel Hill, North Carolina; and Experimental and Systems Pharmacology, College of Pharmacy, Washington State University, Spokane, Washington (G.R.A., M.F.P.)
| | - Yolanda V Scarlett
- Curriculum in Toxicology (G.R.A., M.F.P.) and Division of Gastroenterology and Hepatology (Y.V.S.), School of Medicine, and UNC Eshelman School of Pharmacy (K.K.W., Y.L., E.A.C., J.H.H.), The University of North Carolina, Chapel Hill, North Carolina; and Experimental and Systems Pharmacology, College of Pharmacy, Washington State University, Spokane, Washington (G.R.A., M.F.P.)
| | - J Heyward Hull
- Curriculum in Toxicology (G.R.A., M.F.P.) and Division of Gastroenterology and Hepatology (Y.V.S.), School of Medicine, and UNC Eshelman School of Pharmacy (K.K.W., Y.L., E.A.C., J.H.H.), The University of North Carolina, Chapel Hill, North Carolina; and Experimental and Systems Pharmacology, College of Pharmacy, Washington State University, Spokane, Washington (G.R.A., M.F.P.)
| | - Mary F Paine
- Curriculum in Toxicology (G.R.A., M.F.P.) and Division of Gastroenterology and Hepatology (Y.V.S.), School of Medicine, and UNC Eshelman School of Pharmacy (K.K.W., Y.L., E.A.C., J.H.H.), The University of North Carolina, Chapel Hill, North Carolina; and Experimental and Systems Pharmacology, College of Pharmacy, Washington State University, Spokane, Washington (G.R.A., M.F.P.)
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Auten AA, Beauchamp LN, Joshua Taylor, Hardinger KL. Hidden sources of grapefruit in beverages: potential interactions with immunosuppressant medications. Hosp Pharm 2014; 48:489-93. [PMID: 24421511 DOI: 10.1310/hpj4806-489] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The interaction between grapefruit-containing beverages and immunosuppressants is not well defined in the literature. This study was conducted to investigate possible sources of grapefruit juice or grapefruit extract in common US-manufactured beverages. The goal was to identify those products that might serve as hidden sources of dietary grapefruit intake, increasing a transplant patient's risk for drug interactions. METHODS A careful review of the ingredients of the 3 largest US beverage manufacturer's product lines was conducted through manufacturer correspondence, product labeling examination, and online nutrition database research. Focus was placed on citrus-flavored soft drinks, teas, and juice products and their impact on a patient's immunosuppressant regimens. RESULTS Twenty-three beverages were identified that contained grapefruit. Five did not contain the word "grapefruit" in the product name. In addition to the confirmed grapefruit-containing products, 17 products were identified as possibly containing grapefruit juice or grapefruit extract. CONCLUSION A greater emphasis should be placed upon properly educating patients regarding hidden sources of grapefruit in popular US beverages and the potential for food-drug interactions.
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Affiliation(s)
| | | | | | - Karen L Hardinger
- Clinical Associate Professor of Pharmacy Practice, University of Missouri-Kansas City
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Knops N, Levtchenko E, van den Heuvel B, Kuypers D. From gut to kidney: transporting and metabolizing calcineurin-inhibitors in solid organ transplantation. Int J Pharm 2013; 452:14-35. [PMID: 23711732 DOI: 10.1016/j.ijpharm.2013.05.033] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 05/08/2013] [Accepted: 05/10/2013] [Indexed: 12/14/2022]
Abstract
Since their introduction circa 35 years ago, calcineurin-inhibitors (CNI) have become the cornerstone of immunosuppressive therapy in solid organ transplantation. However, CNI's possess a narrow therapeutic index with potential severe consequences of drug under- or overexposure. This demands a meticulous policy of Therapeutic Drug Monitoring (TDM) to optimize outcome. In clinical practice optimal dosing is difficult to achieve due to important inter- and intraindividual variation in CNI pharmacokinetics. A complex and often interdependent set of factors appears relevant in determining drug exposure. These include recipient characteristics such as age, race, body composition, organ function, and food intake, but also graft-related characteristics such as: size, donor-age, and time after transplantation can be important. Fundamental (in vitro) and clinical studies have pointed out the intrinsic relation between the aforementioned variables and the functional capacity of enzymes and transporters involved in CNI metabolism, primarily located in intestine, liver and kidney. Commonly occurring polymorphisms in genes responsible for CNI metabolism (CYP3A4, CYP3A5, CYP3A7, PXR, POR, ABCB1 (P-gp) and possibly UGT) are able to explain an important part of interindividual variability. In particular, a highly prevalent SNP in CYP3A5 has proven to be an important determinant of CNI dose requirements and drug-dose-interactions. In addition, a discrepancy in genotype between graft and receptor has to be taken into account. Furthermore, common phenomena in solid organ transplantation such as inflammation, ischemia- reperfusion injury, graft function, co-medication, altered food intake and intestinal motility can have a differential effect on the expression enzymes and transporters involved in CNI metabolism. Notwithstanding the built-up knowledge, predicting individual CNI pharmacokinetics and dose requirements on the basis of current clinical and experimental data remains a challenge.
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Affiliation(s)
- Noël Knops
- Department of Pediatric Nephrology and Solid Organ Transplantation, University Hospitals Leuven, Belgium.
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Masuko K, Tohma S, Matsui T. Potential food-drug interactions in patients with rheumatoid arthritis. Int J Rheum Dis 2013; 16:122-8. [DOI: 10.1111/1756-185x.12069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Kayo Masuko
- Graduate School of Nutritional Science; Sagami Women's University; Kanagawa; Japan
| | - Shigeto Tohma
- Department of Rheumatology; National Hospital Organization Sagamihara National Hospital; Kanagawa; Japan
| | - Toshihiro Matsui
- Department of Rheumatology; National Hospital Organization Sagamihara National Hospital; Kanagawa; Japan
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Qin XL, Yu T, Li LJ, Wang Y, Gu HM, Wang YT, Huang M, Bi HC. Effect of long-term co-administration of Wuzhi tablet (Schisandra sphenanthera extract) and prednisone on the pharmacokinetics of tacrolimus. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2013; 20:375-379. [PMID: 23267661 DOI: 10.1016/j.phymed.2012.11.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Tacrolimus (TAC) is an immunosuppressant that has been widely used alone or in combination with prednisone (PRED) to prevent acute rejection after organ transplantation. Wuzhi tablet (WZ, Schisandra sphenanthera extract) is often prescribed with TAC to prevent drug-induced hepatitis. We recently reported that WZ could significantly increase TAC blood exposure by inhibiting P-gp-mediated efflux and CYP3A-mediated metabolism of TAC. PRED is also a substrate of P-gp and is a weak inducer of CYP3A, and drug-drug interactions within this combination therapy might occur. Therefore, the purpose of this study was to investigate the effect of long-term treatment of WZ and PRED on the pharmacokinetics of TAC in rats. After 14 days of co-administration of WZ and PRED, the AUC(0-24h) of oral TAC was increased (from 59.6±37.3 to 95.3±39.4 ng h/ml, p=0.18) and the clearance was decreased (from 38.4±28.4 to 17.7±6.4 l/h/kg, p=0.15). When only co-administered with WZ, AUC(0-24h) of TAC was demonstrated a significantly increase (from 59.6±37.3 to 135.9±34.8 ng h/ml, p<0.05). The concomitant administration of PRED resulted in a reduction in the systemic exposure of TAC and an increase in its clearance, though neither was statistically significant. Thus, our study suggested that the presence of WZ and PRED still could increase the systemic exposure of TAC in rats. The drug-drug interactions among this combination therapy should still be taken into consideration in clinical practice.
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Affiliation(s)
- Xiao-Ling Qin
- Laboratory of Drug Metabolism and Pharmacokinetics, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou 510060, China
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Won CS, Oberlies NH, Paine MF. Mechanisms underlying food-drug interactions: inhibition of intestinal metabolism and transport. Pharmacol Ther 2012; 136:186-201. [PMID: 22884524 DOI: 10.1016/j.pharmthera.2012.08.001] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 07/23/2012] [Indexed: 12/21/2022]
Abstract
Food-drug interaction studies are critical to evaluate appropriate dosing, timing, and formulation of new drug candidates. These interactions often reflect prandial-associated changes in the extent and/or rate of systemic drug exposure. Physiologic and physicochemical mechanisms underlying food effects on drug disposition are well-characterized. However, biochemical mechanisms involving drug metabolizing enzymes and transport proteins remain underexplored. Several plant-derived beverages have been shown to modulate enzymes and transporters in the intestine, leading to altered pharmacokinetic (PK) and potentially negative pharmacodynamic (PD) outcomes. Commonly consumed fruit juices, teas, and alcoholic drinks contain phytochemicals that inhibit intestinal cytochrome P450 and phase II conjugation enzymes, as well as uptake and efflux transport proteins. Whereas myriad phytochemicals have been shown to inhibit these processes in vitro, translation to the clinic has been deemed insignificant or undetermined. An overlooked prerequisite for elucidating food effects on drug PK is thorough knowledge of causative bioactive ingredients. Substantial variability in bioactive ingredient composition and activity of a given dietary substance poses a challenge in conducting robust food-drug interaction studies. This confounding factor can be addressed by identifying and characterizing specific components, which could be used as marker compounds to improve clinical trial design and quantitatively predict food effects. Interpretation and integration of data from in vitro, in vivo, and in silico studies require collaborative expertise from multiple disciplines, from botany to clinical pharmacology (i.e., plant to patient). Development of more systematic methods and guidelines is needed to address the general lack of information on examining drug-dietary substance interactions prospectively.
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Affiliation(s)
- Christina S Won
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7569, USA
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Zheng XE, Wang Z, Liao MZ, Lin YS, Shuhart MC, Schuetz EG, Thummel KE. Human PXR-mediated induction of intestinal CYP3A4 attenuates 1α,25-dihydroxyvitamin D₃ function in human colon adenocarcinoma LS180 cells. Biochem Pharmacol 2012; 84:391-401. [PMID: 22562045 DOI: 10.1016/j.bcp.2012.04.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 04/25/2012] [Accepted: 04/27/2012] [Indexed: 12/12/2022]
Abstract
Oxidative catabolism of 1α,25-dihydroxyvitamin D(3) [1α,25(OH)(2)D(3)] is mediated by either CYP24A1 or CYP3A4. In this paper, we tested whether induction of CYP3A4 in the LS180 intestinal cell model enhances clearance of 1α,25(OH)(2)D(3) and blunts its hormonal effect on expression of the apical membrane calcium transport protein, TRPV6. Treatment with the hPXR agonist rifampin significantly increased CYP3A4 mRNA content and catalytic activity, but had no effect on CYP24A1 or TRPV6 mRNA content. Pre-treating cells with rifampin for 48h, prior to a 24h 1α,25(OH)(2)D(3) treatment phase, was associated with a subsequent 48% increase in the elimination of 1α,25(OH)(2)D(3) and a 35% reduction of peak TRPV6 mRNA. Introduction of the CYP3A4 inhibitor, 6',7'-dihydroxybergamottin, an active inhibitor in grapefruit juice, reversed the effects of rifampin on 1α,25(OH)(2)D(3) clearance and TRPV6 expression. Over-expression of hPXR in LS180 cells greatly enhanced the CYP3A4 responsiveness to rifampin pretreatment, and elicited a greater relative suppression of TRPV6 expression and an increase in 1α,25(OH)(2)D(3) disappearance rate, compared to vector expressed cells, following hormone administration. Together, these results suggest that induction of CYP3A4 in the intestinal epithelium by hPXR agonists can result in a greater metabolic clearance of 1α,25(OH)(2)D(3) and reduced effects of the hormone on the intestinal calcium absorption, which may contribute to an increased risk of drug-induced osteomalacia/osteoporosis in patients receiving chronic therapy with potent hPXR agonists. Moreover, ingestion of grapefruit juice in the at-risk patients could potentially prevent this adverse drug effect.
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Affiliation(s)
- Xi Emily Zheng
- Department of Pharmaceutics, University of Washington, Seattle, WA 98195-7610, United States
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Egashira K, Sasaki H, Higuchi S, Ieiri I. Food-drug interaction of tacrolimus with pomelo, ginger, and turmeric juice in rats. Drug Metab Pharmacokinet 2011; 27:242-7. [PMID: 22123127 DOI: 10.2133/dmpk.dmpk-11-rg-105] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Tacrolimus is a well-known potent immunosuppressant agent, which has various drug-drug or food-drug interactions. Previously, we found a renal transplant recipient who increased tacrolimus blood concentrations after ingestion of pomelo as a rare case. So, we investigated the effect of pomelo after its administration for one day or 3 consecutive days on the pharmacokinetics of tacrolimus in rats. We also confirmed the effects of grapefruit, turmeric, and ginger. The tacrolimus blood concentrations of the rats pre-treated with 100% pomelo juice were significantly higher than those pre-treated with water. On the other hand, the tacrolimus blood concentrations of the rats pre-treated with 50% pomelo juice were not significantly different from those pre-treated with water. The pomelo-tacrolimus interaction showed concentration dependency. Even low concentration of pomelo juice could enhance the blood concentrations of tacrolimus by repeated administration. The inhibitory effect of 100% pomelo juice disappeared 3 days after intake. The AUC values of tacrolimus in the rats pre-treated with grapefruit juice, ginger juice, and turmeric juice were significantly larger than those pre-treated with water. We could confirm the pomelo-tacrolimus interaction, which we discovered in a case study, quantitatively. We newly found the influence of turmeric and ginger on tacrolimus pharmacokinetics, comparable to pomelo.
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Affiliation(s)
- Kanoko Egashira
- Department of Hospital Pharmacy, Nagasaki University Hospital, Nagasaki
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Effects of Schisandra sphenanthera extract on the blood concentration of tacrolimus in renal transplant recipients. Eur J Clin Pharmacol 2011; 67:1309-11. [DOI: 10.1007/s00228-011-1075-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 05/26/2011] [Indexed: 10/18/2022]
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Won CS, Oberlies NH, Paine MF. Influence of dietary substances on intestinal drug metabolism and transport. Curr Drug Metab 2011; 11:778-92. [PMID: 21189136 DOI: 10.2174/138920010794328869] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Accepted: 11/20/2010] [Indexed: 11/22/2022]
Abstract
Successful delivery of promising new chemical entities via the oral route is rife with challenges, some of which cannot be explained or foreseen during drug development. Further complicating an already multifaceted problem is the obvious, yet often overlooked, effect of dietary substances on drug disposition and response. Some dietary substances, particularly fruit juices, have been shown to inhibit biochemical processes in the intestine, leading to altered pharmacokinetic (PK), and potentially pharmacodynamic (PD), outcomes. Inhibition of intestinal CYP3Amediated metabolism is the major mechanism by which fruit juices, including grapefruit juice, enhances systemic exposure to new and already marketed drugs. Inhibition of intestinal non-CYP3A enzymes and apically-located transport proteins represent recently identified mechanisms that can alter PK and PD. Several fruit juices have been shown to inhibit these processes in vitro, but some interactions have not translated to the clinic. The lack of in vitroin vivo concordance is due largely to a lack of rigorous methods to elucidate causative ingredients prior to clinical testing. Identification of specific components and underlying mechanisms is challenging, as dietary substances frequently contain multiple, often unknown, bioactive ingredients that vary in composition and bioactivity. A translational research approach, combining expertise from clinical pharmacologists and natural products chemists, is needed to develop robust models describing PK/PD relationships between a given dietary substance and drug of interest. Validation of these models through well-designed clinical trials would facilitate development of common practice guidelines for managing drug-dietary substance interactions appropriately.
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Affiliation(s)
- Christina S Won
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7569, USA
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Smart KM, Alex G, Hardikar W. Feeding the child with liver disease: a review and practical clinical guide. J Gastroenterol Hepatol 2011; 26:810-5. [PMID: 21299619 DOI: 10.1111/j.1440-1746.2011.06687.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Nourishing children with liver disease is a challenging task; however, appropriate assessment and well-timed nutritional interventions are paramount for a good long-term outcome in these patients. An appropriate balance of macronutrients, micronutrients, and vitamins is important, as is the route of administration. This review aims to highlight the practical points in nutrition assessment and also provides a guide to the various nutritional interventions available for children with chronic liver disease.
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Abstract
Grapefruit juice and grapefruit product consumption have potential health benefits; however, their intake is also associated with interactions with certain drugs, including calcium channel blockers, immunosuppressants and antihistamines. The primary mechanism through which interactions are mediated is mechanism-based intestinal cytochrome P450 3A4 inhibition by furanocoumarins resulting in increased bioavailability of administered medications that are substrates. Grapefruit products have also been associated with interactions with P-glycoprotein (P-gp) and uptake transporters (e.g. organic anion-transporting polypeptides [OATPs]). Polyphenolic compounds such as flavonoids have been proposed as the causative agents of the P-gp and OATP interactions. The mechanisms and magnitudes of the interactions can be influenced by the concentrations of furanocoumarins and flavonoids in the grapefruit product, the volume of juice consumed, and the inherent variability of specific enzymes and transporter components in humans. It is therefore challenging to predict the extent of grapefruit product-drug interactions and to compare available in vitro and in vivo data. The clinical significance of such interactions also depends on the disposition and toxicity profile of the drug being administered. The aim of this review is to outline the mechanisms of grapefruit-drug interactions and present a comprehensive summary of those agents affected and whether they are likely to be of clinical relevance.
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Affiliation(s)
- Kay Seden
- NIHR Biomedical Research Centre, Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, UK.
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Hanley MJ, Cancalon P, Widmer WW, Greenblatt DJ. The effect of grapefruit juice on drug disposition. Expert Opin Drug Metab Toxicol 2011; 7:267-86. [PMID: 21254874 DOI: 10.1517/17425255.2011.553189] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Since their initial discovery in 1989, grapefruit juice (GFJ)-drug interactions have received extensive interest from the scientific, medical, regulatory and lay communities. Although knowledge regarding the effects of GFJ on drug disposition continues to expand, the list of drugs studied in the clinical setting remains relatively limited. AREAS COVERED This article reviews the in vitro effects of GFJ and its constituents on the activity of CYP enzymes, organic anion-transporting polypeptides (OATPs), P-glycoprotein, esterases and sulfotransferases. The translational applicability of the in vitro findings to the clinical setting is discussed for each drug metabolizing enzyme and transporter. Reported AUC ratios for available GFJ-drug interaction studies are also provided. Relevant investigations were identified by searching the PubMed electronic database from 1989 to 2010. EXPERT OPINION GFJ increases the bioavailability of some orally administered drugs that are metabolized by CYP3A and normally undergo extensive presystemic extraction. In addition, GFJ can decrease the oral absorption of a few drugs that rely on OATPs in the gastrointestinal tract for their uptake. The number of drugs shown to interact with GFJ in vitro is far greater than the number of clinically relevant GFJ-drug interactions. For the majority of patients, complete avoidance of GFJ is unwarranted.
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Affiliation(s)
- Michael J Hanley
- Tufts University School of Medicine, Program in Pharmacology and Experimental Therapeutics, 136 Harrison Avenue, Boston, MA 02111, USA
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Different influences on tacrolimus pharmacokinetics by coadministrations of zhi ke and zhi shi in rats. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2011; 2011:751671. [PMID: 21318106 PMCID: PMC3035000 DOI: 10.1155/2011/751671] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 10/19/2010] [Accepted: 12/28/2010] [Indexed: 11/18/2022]
Abstract
Tacrolimus, an immunosuppressant with narrow therapeutic window, has been used widely in transplant patients. Grapefruit juice and pomelo have been reported to increase the blood levels of tacrolimus. Zhi Ke and Zhi Shi, the ripe peels and unripe fruits of Citrus aurantium which is chemotaxonomically related to grapefruit and pomelo, are in wide use in clinical Chinese medicine. To investigate the possible interaction of these two Citrus herbs with tacrolimus, male Sprague-Dawley rats were orally given tacrolimus (1.5 mg/kg) with and without Zhi Ke and Zhi Shi decoctions in a cross-over design. Blood samples were withdrawn via cardiopuncture at specific time and quantitated by a microparticle enzyme immunoassay. In addition, to explore the mechanism of interaction, LS 180 cell line was used for the transport study of rhodamine 123, a typical substrate of P-glycoprotein (P-gp). The results showed that Zhi Shi significantly decreased the Cmax and AUC0−t of tacrolimus by 72.4% and 72.0%, respectively, whereas Zhi Ke did not affect tacrolimus pharmacokinetics. LS 180 cell line study indicated that Zhi Shi increased the efflux activity of P-gp, enabling us to explain the decreased oral bioavailability of tacrolimus caused by Zhi Shi. Hence, we suggest that Zhi Shi be contraindicated for transplant patients treated with tacrolimus to reduce the risk of allograft rejection.
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