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Sun CK, Kung YY, Lee WH, Lin LC, Yang MH, Tsai TH. Pharmacokinetic analysis of antiviral drug ritonavir across the blood-brain barrier and its interaction with Scutellaria baicalensis using multisite microdialysis in rats. J Pharm Biomed Anal 2024; 245:116162. [PMID: 38678857 DOI: 10.1016/j.jpba.2024.116162] [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] [Received: 02/23/2024] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 05/01/2024]
Abstract
Ritonavir, an excellent inhibitor of CYP3A4, has recently been combined with nirmatrelvir to form Paxlovid for the treatment of severe acute respiratory syndrome coronavirus 2 infections. The root of Scutellaria baicalensis Georgi (S. baicalensis), a traditional Chinese medicinal (TCM) herb commonly used to treat heat/inflammation in the lung and digestive tracts, which are major organs targeted by viral infections, contains flavones that can influence the CYP3A metabolism pathway. To investigate the ability of ritonavir to cross the bloodbrain barrier (BBB) and its potential herb-drug interactions with an equivalent TCM clinical dose of S. baicalensis, multisite microdialysis coupled with an LCMS/MS system was developed using rat model. Pretreatment with S. baicalensis extract for 5 days, which contains less flavones than those used in previous studies, had a significant influence on ritonavir, resulting in a 2-fold increase in the total concentration of flavones in the blood and brain. Treatment also boosted the maximum blood concentration of flavones by 1.5-fold and the maximum brain concentration of flavones by 2-fold, all the while exerting no noticeable influence on the transfer ratio across the bloodbrain barrier. These experimental results demonstrated that the use of a typical traditional Chinese medicinal dose of S. baicalensis is sufficient to influence the metabolic pathway and synergistically increase the concentration of ritonavir in rats.
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Affiliation(s)
- Chung-Kai Sun
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Yen-Ying Kung
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Wan-Hsin Lee
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Lie-Chwen Lin
- National Research Institute of Chinese Medicine, Ministry of Health and Welfare, Taipei 112, Taiwan
| | - Muh-Hwa Yang
- Institute of Clinical Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Tung-Hu Tsai
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; Graduate Institute of Acupuncture Science, China Medical University, Taichung 404, Taiwan; School of Pharmacy, Kaohsiung Medical University, Kaohsiung 807, Taiwan; Graduate Institute of Law and Interdisciplinary Studies, College of Law, National Chengchi University, Taipei 116, Taiwan.
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Kokott M, Breitkreutz J, Wiedey R. The interplay of poorly soluble drugs in dissolution from amorphous solid dispersions. Int J Pharm X 2024; 7:100243. [PMID: 38585343 PMCID: PMC10997824 DOI: 10.1016/j.ijpx.2024.100243] [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: 01/02/2024] [Revised: 03/27/2024] [Accepted: 03/29/2024] [Indexed: 04/09/2024] Open
Abstract
In recent years, the application of fixed dose combinations of antiretroviral drugs in HIV therapy has been established. Despite numerous therapeutic benefits, this approach poses several challenges for the formulation development especially when poorly soluble drugs are considered. Amorphous solid dispersions (ASD) thereby have gained considerable interest in the pharmaceutical field, however, mainly including binary systems containing only one drug and a polymer. The co-formulation of two amorphous drugs can be accompanied by an immense increase in the complexity of the system as exemplarily reported for ritonavir and lopinavir embedded in a composite polymer matrix of PVPVA. The present study aims to present a new formulation approach to overcome the well-documented interaction during dissolution. Two different polymers, PVPVA and HPMCAS were used to produce ASDs for both drugs individually via hot-melt extrusion. The embedding of lopinavir in the slower dissolving polymer HPMCAS, while using PVPVA for ritonavir was found to significantly improve the overall dissolution performance compared to the individual use of PVPVA as well as to the commercial product Kaletra®. In addition, the use of different grades of HPMCAS demonstrated the possibility to further modify the dissolution profile. For a preliminary biorelevant assessment, the selected formulations were tested in a biphasic dissolution setup.
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Affiliation(s)
- Marcel Kokott
- Institute of Pharmaceutics and Biopharmaceutics, Heinrich Heine University, Duesseldorf Universitaetsstr. 1, Duesseldorf 40225, Germany
| | - Jörg Breitkreutz
- Institute of Pharmaceutics and Biopharmaceutics, Heinrich Heine University, Duesseldorf Universitaetsstr. 1, Duesseldorf 40225, Germany
| | - Raphael Wiedey
- Institute of Pharmaceutics and Biopharmaceutics, Heinrich Heine University, Duesseldorf Universitaetsstr. 1, Duesseldorf 40225, Germany
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Rohr BS, Krohmer E, Foerster KI, Burhenne J, Schulz M, Blank A, Mikus G, Haefeli WE. Time Course of the Interaction Between Oral Short-Term Ritonavir Therapy with Three Factor Xa Inhibitors and the Activity of CYP2D6, CYP2C19, and CYP3A4 in Healthy Volunteers. Clin Pharmacokinet 2024; 63:469-481. [PMID: 38393578 PMCID: PMC11052790 DOI: 10.1007/s40262-024-01350-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND We investigated the effect of a 5-day low-dose ritonavir therapy, as it is used in the treatment of COVID-19 with nirmatrelvir/ritonavir, on the pharmacokinetics of three factor Xa inhibitors (FXaI). Concurrently, the time course of the activities of the cytochromes P450 (CYP) 3A4, 2C19, and 2D6 was assessed. METHODS In an open-label, fixed sequence clinical trial, the effect and duration of a 5-day oral ritonavir (100 mg twice daily) treatment on the pharmacokinetics of three oral microdosed FXaI (rivaroxaban 25 µg, apixaban 25 µg, and edoxaban 50 µg) and microdosed probe drugs (midazolam 25 µg, yohimbine 50 µg, and omeprazole 100 µg) was evaluated in eight healthy volunteers. The plasma concentrations of all drugs were quantified using validated liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods and pharmacokinetics were analysed using non-compartmental analyses. RESULTS Ritonavir increased the exposure of apixaban, edoxaban, and rivaroxaban, but to a different extent the observed area under the plasma concentration-time curve (geometric mean ratio 1.29, 1.46, and 1.87, respectively). A strong CYP3A4 inhibition (geometric mean ratio > 10), a moderate CYP2C19 induction 2 days after ritonavir (0.64), and no alteration of CYP2D6 were observed. A CYP3A4 recovery half-life of 2.3 days was determined. CONCLUSION This trial with three microdosed FXaI suggests that at most the rivaroxaban dose should be reduced during short-term ritonavir, and only in patients receiving high maintenance doses. Thorough time series analyses demonstrated differential effects on three different drug-metabolising enzymes over time with immediate profound inhibition of CYP3A4 and only slow recovery after discontinuation. CLINICAL TRIAL REGISTRATION EudraCT number: 2021-006643-39.
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Affiliation(s)
- Brit S Rohr
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Evelyn Krohmer
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Martin Schulz
- Drug Commission of German Pharmacists and Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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Sun CK, Lee WH, Yang MH, Tsai TH. Pharmacokinetic analysis of placental transfer of ritonavir as a component of paxlovid using microdialysis in pregnant rats. Heliyon 2024; 10:e24333. [PMID: 38293424 PMCID: PMC10826739 DOI: 10.1016/j.heliyon.2024.e24333] [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: 07/27/2023] [Revised: 01/05/2024] [Accepted: 01/07/2024] [Indexed: 02/01/2024] Open
Abstract
Background Ritonavir is one of the most potent CYP3A4 inhibitor currently on the market, and is often used together with other antiviral drugs to increase their bioavailability and efficacy. Paxlovid, consisting of nirmatrelvir and ritonavir, was approved for the treatment of COVID-19. As previous studies regarding the use of ritonavir during pregnancy were limited to ex-vivo experiments and systemic safety data, to fully explore the detailed pharmacokinetics of ritonavir in pregnant rats' blood and conceptus, an analytical method consisted of multi-microdialysis coupled with UHPLC-MS/MS were developed to analyze the pharmacokinetics of ritonavir, both as a component of Paxlovid and by itself. 17 days pregnant female Sprague-Dawley rats were randomly split into three experimental group: normal dosage of ritonavir alone (7 mg kg-1), normal dosage of Paxlovid (ritonavir 7 mg kg-1 + nirmatrelvir 15 mg kg-1), and 3× dosage of ritonavir (21 mg kg-1). Results 3× dosage of ritonavir produced a more than 3× increase in rats' blood and placenta. Transfer rate of ritonavir to the placenta, amniotic fluid, and fetus were determined to be 20.7%, 13.8%, and 4.7% respectively. Concentration of ritonavir in the placenta, amniotic fluid, and fetus did not significantly go down after 8 h. Significance Overall, ritonavir's metabolism was not influenced by the presence of nirmatrelvir in pregnant rats. A 3× increase in dosage produced a concentration of roughly 4×, most likely a result of ritonavir's auto-inhibition effect on cytochrome P450 proteins. Accumulation of ritonavir is possible in placenta, amniotic fluid, and fetus.
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Affiliation(s)
- Chung-Kai Sun
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Wan-Hsin Lee
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Muh-Hwa Yang
- Institute of Clinical Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Tung-Hu Tsai
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Graduate Institute of Acupuncture Science, China Medical University, Taichung 404, Taiwan
- Department of Chemistry, National Sun Yat-Sen University, Kaohsiung 804, Taiwan
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung 807, Taiwan
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Krohmer E, Rohr BS, Stoll F, Gümüs KS, Bergamino M, Mikus G, Sauter M, Burhenne J, Weiss J, Meid AD, Czock D, Blank A, Haefeli WE. Influence of a Short Course of Ritonavir Used as Booster in Antiviral Therapies Against SARS-CoV-2 on the Exposure of Atorvastatin and Rosuvastatin. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07538-w. [PMID: 38112932 DOI: 10.1007/s10557-023-07538-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE Early antiviral treatment with nirmatrelvir/ritonavir is recommended for SARS-CoV-2-infected patients at high risk for severe courses. Such patients are usually chronically ill and susceptible to adverse drug interactions caused by ritonavir. We investigated the interactions of short-term low-dose ritonavir therapy with atorvastatin and rosuvastatin, two statins commonly used in this population. METHOD We assessed exposure changes (area under the concentration-time curve (AUC∞) and maximum concentration (Cmax)) of a single dose of 10 mg atorvastatin and 10 mg rosuvastatin before and on the fifth day of ritonavir treatment (2 × 100 mg/day) in healthy volunteers and developed a semi-mechanistic pharmacokinetic model to estimate dose adjustment of atorvastatin during ritonavir treatment. RESULTS By the fifth day of ritonavir treatment, the AUC∞ of atorvastatin increased 4.76-fold and Cmax 3.78-fold, and concurrently, the concentration of atorvastatin metabolites decreased to values below the lower limit of quantification. Pharmacokinetic modelling indicated that a stepwise reduction in atorvastatin dose during ritonavir treatment with a stepwise increase up to 4 days after ritonavir discontinuation can keep atorvastatin exposure within safe and effective margins. Rosuvastatin pharmacokinetics were only mildly modified; ritonavir significantly increased the Cmax 1.94-fold, while AUC∞ was unchanged. CONCLUSION Atorvastatin doses should likely be adjusted during nirmatrelvir/ritonavir treatment. For patients on a 20-mg dose, we recommend half of the original dose. In patients taking 40 mg or more, a quarter of the dose should be taken until 2 days after discontinuation of nirmatrelvir/ritonavir. Patients receiving rosuvastatin do not need to change their treatment regimen. TRIAL REGISTRATION EudraCT number: 2021-006634-39. DRKS00027838.
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Affiliation(s)
- Evelyn Krohmer
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Brit Silja Rohr
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Felicitas Stoll
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Katja S Gümüs
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Mariano Bergamino
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Max Sauter
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Johanna Weiss
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - David Czock
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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Sagawa K, Lin J, Jaini R, Di L. Physiologically-Based Pharmacokinetic Modeling of PAXLOVID™ with First-Order Absorption Kinetics. Pharm Res 2023; 40:1927-1938. [PMID: 37231296 PMCID: PMC10212229 DOI: 10.1007/s11095-023-03538-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE PAXLOVID™ is nirmatrelvir tablets co-packaged with ritonavir tablets. Ritonavir is used as a pharmacokinetics (PK) enhancer to reduce metabolism and increase exposure of nirmatrelvir. This is the first disclosure of Paxlovid physiologically-based pharmacokinetic (PBPK) model. METHODS Nirmatrelvir PBPK model with first-order absorption kinetics was developed using in vitro, preclinical, and clinical data of nirmatrelvir in the presence and absence of ritonavir. Clearance and volume of distribution were derived from nirmatrelvir PK obtained using a spray-dried dispersion (SDD) formulation where it is considered to be dosed as an oral solution, and absorption is near complete. The fraction of nirmatrelvir metabolized by CYP3A was estimated based on in vitro and clinical ritonavir drug-drug interaction (DDI) data. First-order absorption parameters were established for both SDD and tablet formulation using clinical data. Nirmatrelvir PBPK model was verified with both single and multiple dose human PK data, as well as DDI studies. Simcyp® first-order ritonavir compound file was also verified with additional clinical data. RESULTS The nirmatrelvir PBPK model described the observed PK profiles of nirmatrelvir well with predicted AUC and Cmax values within ± 20% of the observed. The ritonavir model performed well resulting in predicted values within twofold of observed. CONCLUSIONS Paxlovid PBPK model developed in this study can be applied to predict PK changes in special populations, as well as model the effect of victim and perpetrator DDI. PBPK modeling continues to play a critical role in accelerating drug discovery and development of potential treatments for devastating diseases such as COVID-19. NCT05263895, NCT05129475, NCT05032950 and NCT05064800.
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Affiliation(s)
- Kazuko Sagawa
- Pharmaceutical Science, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, CT, 06340, USA
| | - Jian Lin
- Pharmacokinetics, Dynamics and Metabolism, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, CT, 06340, USA
| | - Rohit Jaini
- Pharmaceutical Science, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, CT, 06340, USA
- Pharmaceutical Science, Pfizer Worldwide Research and Development, 1 Portland Street, Cambridge, MA, 02139, USA
| | - Li Di
- Pharmacokinetics, Dynamics and Metabolism, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, CT, 06340, USA.
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Ellis C, Inaba K, Van de Vuurst C, Ghrayeb A, Cory TJ. Drug-drug interactions between COVID-19 therapeutics and antiretroviral treatment: the evidence to date. Expert Opin Drug Metab Toxicol 2023; 19:795-806. [PMID: 37800561 PMCID: PMC10841549 DOI: 10.1080/17425255.2023.2267970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 10/04/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION With new effective treatments for SARS-CoV-2, patient outcomes have greatly improved. However, new medications bring a risk of drug interactions with other medications. People living with HIV (PLWH) are at particular risk for these interactions due to heightened risk of immunosuppression, polypharmacy, and overlap in affected organs. It is critical to identify drug interactions are a significant barrier to care for PLWH. Establishing a better understanding of the pharmacologic relationships between COVID-19 therapies and antiretrovirals will improve patient-centered care in COVID-19. AREAS COVERED Potential drug-drug interactions between Human Immunodeficiency Virus (HIV) and COVID-19 treatments are detailed and reviewed here. The mechanisms seen in these interactions include alterations in metabolic enzymes, drug transporters, pharmacoenhancement, and organ toxicities. We also review the limitations and solutions that can be used to combat drug-drug interactions between these two disease states. EXPERT OPINION While current drug interactions are relatively mild between HIV and COVID-19 therapies, improvements in identifying these beforehand must take place as new therapies are approved. Antiretroviral therapy (ART) is essential in PLWH and must be maintained when treating COVID-19. As advancements in care occur, there is the possibility that newly approved drugs may have additional unknown interactions.
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Affiliation(s)
- Camden Ellis
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, USA
| | - Keita Inaba
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, USA
| | - Christine Van de Vuurst
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, USA
| | - Atheel Ghrayeb
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, USA
| | - Theodore James Cory
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, USA
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Loos NH, Beijnen JH, Schinkel AH. The inhibitory and inducing effects of ritonavir on hepatic and intestinal CYP3A and other drug-handling proteins. Biomed Pharmacother 2023; 162:114636. [PMID: 37004323 PMCID: PMC10065864 DOI: 10.1016/j.biopha.2023.114636] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/21/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Ritonavir, originally developed as HIV protease inhibitor, is widely used as a booster in several HIV pharmacotherapy regimens and more recently in Covid-19 treatment (e.g., Paxlovid). Its boosting capacity is due to the highly potent irreversible inhibition of the cytochrome P450 (CYP) 3 A enzyme, thereby enhancing the plasma exposure to coadministered drugs metabolized by CYP3A. Typically used booster doses of ritonavir are 100-200 mg once or twice daily. This review aims to address several aspects of this booster drug, including the possibility to use lower ritonavir doses, 20 mg for instance, resulting in partial CYP3A inactivation in patients. If complete CYP3A inhibition is not needed, lower ritonavir doses could be used, thereby reducing unwanted side effects. In this context, there are contradictory reports on the actual recovery time of CYP3A activity after ritonavir discontinuation, but probably this will take at least one day. In addition to ritonavir's CYP3A inhibitory effect, it can also induce and/or inhibit other CYP enzymes and drug transporters, albeit to a lesser extent. Although ritonavir thus exhibits gene induction capacities, with respect to CYP3A activity the inhibition capacity clearly predominates. Another potent CYP3A inhibitor, the ritonavir analog cobicistat, has been reported to lack the ability to induce enzyme and transporter genes. This might result in a more favorable drug-drug interaction profile compared to ritonavir, although the actual benefit appears to be limited. Indeed, ritonavir is still the clinically most used pharmacokinetic enhancer, indicating that its side effects are well manageable, even in chronic administration regimens.
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Chen S, Leong WF, Lee SS, Chowbay B. Pharmacokinetic and pharmacogenomic considerations in managing use of nirmatrelvir-ritonavir and molnupiravir and dermatological treatments. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022. [DOI: 10.47102/annals-acadmedsg.2022430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Marzolini C, Kuritzkes DR, Marra F, Boyle A, Gibbons S, Flexner C, Pozniak A, Boffito M, Waters L, Burger D, Back DJ, Khoo S. Recommendations for the Management of Drug-Drug Interactions Between the COVID-19 Antiviral Nirmatrelvir/Ritonavir (Paxlovid) and Comedications. Clin Pharmacol Ther 2022; 112:1191-1200. [PMID: 35567754 PMCID: PMC9348462 DOI: 10.1002/cpt.2646] [Citation(s) in RCA: 108] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The coronavirus disease 2019 (COVID-19) antiviral nirmatrelvir/ritonavir (Paxlovid) has been granted authorization or approval in several countries for the treatment of patients with mild to moderate COVID-19 at high risk of progression to severe disease and with no requirement for supplemental oxygen. Nirmatrelvir/ritonavir will be primarily administered outside the hospital setting as a 5-day course oral treatment. The ritonavir component boosts plasma concentrations of nirmatrelvir through the potent and rapid inhibition of the key drug-metabolizing enzyme cytochrome P450 (CYP) 3A4. Thus nirmatrelvir/ritonavir, even given as a short treatment course, has a high potential to cause harm from drug-drug interactions (DDIs) with other drugs metabolized through this pathway. Options for mitigating risk from DDIs with nirmatrelvir/ritonavir are limited due to the clinical illness, the short window for intervention, and the related difficulty of implementing clinical monitoring or dosage adjustment of the comedication. Pragmatic options are largely confined to preemptive or symptom-driven pausing of the comedication or managing any additional risk through counseling. This review summarizes the effects of ritonavir on drug disposition (i.e., metabolizing enzymes and transporters) and discusses factors determining the likelihood of having a clinically significant DDI. Furthermore, it provides a comprehensive list of comedications likely to be used in COVID-19 patients which are categorized according to their potential DDI risk with nirmatrelvir/ritonavir. It also discusses recommendations for the management of DDIs which balance the risk of harm from DDIs with a short course of ritonavir, against unnecessary denial of nirmatrelvir/ritonavir treatment.
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Affiliation(s)
- Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital of Basel and University of Basel, Basel, Switzerland
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Daniel R Kuritzkes
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Fiona Marra
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
- Department of Pharmacy, National Health Service Greater Glasgow and Clyde, Glasgow, UK
| | - Alison Boyle
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
- Department of Pharmacy, National Health Service Greater Glasgow and Clyde, Glasgow, UK
| | - Sara Gibbons
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Charles Flexner
- Divisions of Clinical Pharmacology and Infectious Diseases, School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Anton Pozniak
- Chelsea and Westminster Hospital National Health Service Foundation Trust, London, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - Marta Boffito
- Chelsea and Westminster Hospital National Health Service Foundation Trust, London, UK
| | - Laura Waters
- Mortimer Market Centre, Central and North West London, National Health Service Foundation Trust, London, UK
| | - David Burger
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
- Global DDI Solutions, Utrecht, The Netherlands
| | - David J Back
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Saye Khoo
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
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Svedmyr A, Hack H, Anderson BJ. Interactions of the protease inhibitor, ritonavir, with common anesthesia drugs. Paediatr Anaesth 2022; 32:1091-1099. [PMID: 35842922 PMCID: PMC9543968 DOI: 10.1111/pan.14529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 11/27/2022]
Abstract
The protease inhibitor, ritonavir, is a strong inhibitor of CYP 3A. The drug is used for management of the human immunovirus and is currently part of an oral antiviral drug combination (nirmatrelvir-ritonavir) for the early treatment of SARS-2 COVID-19-positive patients aged 12 years and over who have recognized comorbidities. The CYP 3A enzyme system is responsible for clearance of numerous drugs used in anesthesia (e.g., alfentanil, fentanyl, methadone, rocuronium, bupivacaine, midazolam, ketamine). Ritonavir will have an impact on drug clearances that are dependent on ritonavir concentration, anesthesia drug intrinsic hepatic clearance, metabolic pathways, concentration-response relationship, and route of administration. Drugs with a steep concentration-response relationship (ketamine, midazolam, rocuronium) are mostly affected because small changes in concentration have major changes in effect response. An increase in midazolam concentration is observed after oral administration because CYP 3A in the gastrointestinal wall is inhibited, causing a large increase in relative bioavailability. Fentanyl infusion may be associated with a modest increase in plasma concentration and effect, but the large between subject variability of pharmacokinetic and pharmacodynamic concentration changes suggests it will have little impact on an individual patient, especially when used with adverse effect monitoring. It has been proposed that drugs that have no or only a small metabolic pathway involving the CYP 3A enzyme be used during anesthesia, for example, propofol, atracurium, remifentanil, and the volatile agents. That anesthesia approach denies children of drugs with considerable value. It is better that the inhibitory changes in clearance of these drugs are understood so that rational drug choices can be made to tailor drug use to the individual patient. Altered drug dose, anticipation of duration of effect, timing of administration, use of reversal agents and perioperative monitoring would better behoove children undergoing anesthesia.
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Affiliation(s)
- Anders Svedmyr
- Dept AnaesthesiaStarship Children's HospitalAucklandNew Zealand
| | - Henrik Hack
- Dept AnaesthesiaStarship Children's HospitalAucklandNew Zealand
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Clinically Relevant Interactions Between Ritonavir-Boosted Nirmatrelvir and Concomitant Antiseizure Medications: Implications for the Management of COVID-19 in Patients with Epilepsy. Clin Pharmacokinet 2022; 61:1219-1236. [PMID: 35895276 PMCID: PMC9325946 DOI: 10.1007/s40262-022-01152-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2022] [Indexed: 01/06/2023]
Abstract
Ritonavir-boosted nirmatrelvir (RBN) has been authorized recently in several countries as an orally active anti-SARS-CoV-2 treatment for patients at high risk of progressing to severe COVID-19 disease. Nirmatrelvir is the active component against the SARS-CoV-2 virus, whereas ritonavir, a potent CYP3A inhibitor, is intended to boost the activity of nirmatrelvir by increasing its concentration in plasma to ensure persistence of antiviral concentrations during the 12-hour dosing interval. RBN is involved in many clinically important drug–drug interactions both as perpetrator and as victim, which can complicate its use in patients treated with antiseizure medications (ASMs). Interactions between RBN and ASMs are bidirectional. As perpetrator, RBN may increase the plasma concentration of a number of ASMs that are CYP3A4 substrates, possibly leading to toxicity. As victims, both nirmatrelvir and ritonavir are subject to metabolic induction by concomitant treatment with potent enzyme-inducing ASMs (carbamazepine, phenytoin, phenobarbital and primidone). According to US and European prescribing information, treatment with these ASMs is a contraindication to the use of RBN. Although remdesivir is a valuable alternative to RBN, it may not be readily accessible in some settings due to cost and/or need for intravenous administration. If remdesivir is not an appropriate option, either bebtelovimab or molnupiravir may be considered. However, evidence about the clinical efficacy of bebtelovimab is still limited, and molnupiravir, the only orally active alternative, is deemed to have appreciably lower efficacy than RBN and remdesivir.
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Arora S, Pansari A, Kilford PJ, Jamei M, Turner DB, Gardner I. A Mechanistic Absorption and Disposition Model of Ritonavir to Predict Exposure and Drug-Drug Interaction Potential of CYP3A4/5 and CYP2D6 Substrates. Eur J Drug Metab Pharmacokinet 2022; 47:483-495. [PMID: 35486324 DOI: 10.1007/s13318-022-00765-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Due to health authority warnings and the recommended limited use of ketoconazole as a model inhibitor of cytochrome P450 (CYP) 3A4 in clinical drug-drug interaction (DDI) studies, there is a need to search for alternatives. Ritonavir is a strong inhibitor for CYP3A4/5-mediated DDIs and has been proposed as a suitable alternative to ketoconazole. It can also be used as a weak inhibitor for CYP2D6-mediated DDIs. Most of the currently available physiologically based pharmacokinetic (PBPK) inhibitor models developed for predicting DDIs use first-order absorption models, which do not mechanistically capture the effect of formulations on the systemic exposure of the inhibitor. Thus, the main purpose of the current study was to verify the predictive performance of a mechanistic absorption and disposition model of ritonavir when it was applied to the inhibition of CYP2D6 and CYP3A4/5 by ritonavir. METHODS A PBPK model that incorporates formulation characteristics and enzyme kinetic parameters for post-absorptive pharmacokinetic processes of ritonavir was constructed. Key absorption-related parameters in the model were determined using mechanistic modelling of in vitro biopharmaceutics experiments. The model was verified for systemic exposure and DDI risk assessment using clinical observations from 13 and 18 studies, respectively. RESULTS Maximal inhibition of hepatic (3.53% of the activity remaining) and gut (5.16% of the activity remaining) CYP3A4 activity was observed when ritonavir was orally administered in doses of 100 mg or higher. The PBPK model accurately described the concentrations of ritonavir in the different simulated studies. The prediction accuracy for maximum concentration (Cmax) and area under the plasma concentration versus time curve (AUC) were assessed. The bias (average fold error, AFE) for the prediction of Cmax and AUC was 0.92 and 1.06, respectively, and the precision (absolute average fold error, AAFE) was 1.29 and 1.23, respectively. The PBPK model predictions for all Cmax and AUC ratios when ritonavir was used as an inhibitor of CYP metabolism fell within twofold of the clinical observations. The prediction accuracy for Cmax and AUC ratios had a bias (AFE) of 0.85 and 0.99, respectively, and a precision (AAFE) of 1.21 and 1.33, respectively. CONCLUSIONS The current model, which incorporates formulation characteristics and mechanistic disposition parameters, can be used to assess the DDI potential of CYP3A4/5 and CYP2D6 substrates administered with a twice-daily dose of 100 mg of ritonavir for 14 days.
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Affiliation(s)
- Sumit Arora
- Certara UK Limited, Simcyp Division, Level 2 Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK. .,Janssen Pharmaceutical, Companies of Johnson & Johnson, Turnhoutseweg 30, 2340, Beerse, Belgium.
| | - Amita Pansari
- Certara UK Limited, Simcyp Division, Level 2 Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Peter J Kilford
- Certara UK Limited, Simcyp Division, Level 2 Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK.
| | - Masoud Jamei
- Certara UK Limited, Simcyp Division, Level 2 Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - David B Turner
- Certara UK Limited, Simcyp Division, Level 2 Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Iain Gardner
- Certara UK Limited, Simcyp Division, Level 2 Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK
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Mikus G, I. Foerster K, Terstegen T, Vogt C, Said A, Schulz M, E. Haefeli W. Oral Drugs Against COVID-19. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:263-269. [PMID: 35302484 PMCID: PMC9400198 DOI: 10.3238/arztebl.m2022.0152] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/05/2022] [Accepted: 02/16/2022] [Indexed: 05/05/2023]
Abstract
BACKGROUND Five-day oral therapies against early COVID-19 infection have recently been conditionally approved in Europe. In the drug combination nirmatrelvir + ritonavir (nirmatrelvir/r), the active agent, nirmatrelvir, is made bioavailable in clinically adequate amounts by the additional administration of a potent inhibitor of its first-pass metabolism by way of cytochrome P450 [CYP] 3A in the gut and liver. In view of the central role of CYP3A in the clearance of many different kinds of drugs, and the fact that many patients with COVID-19 are taking multiple drugs to treat other conditions, it is important to assess the potential for drug interactions when nirmatrelvir/r is given, and to minimize the risks associated with such interactions. METHODS We defined the interaction profile of ritonavir on the basis of information derived from two databases (Medline, GoogleScholar), three standard electronic texts on drug interactions, and manufacturer-supplied drug information. We compiled a list of drugs and their potentially relevant interactions, developed a risk min - imization algorithm, and applied it to the substances in question. We also compiled a list of commonly prescribed drugs for which there is no risk of interaction with nirmatrelvir/r. RESULTS Out of 190 drugs and drug combinations, 57 do not need any special measures when given in combination with brief, low-dose ritonavir treatment, while 15 require dose modification or a therapeutic alternative, 8 can be temporarily discontinued, 9 contraindicate ritonavir use, and 102 should preferably be combined with a different treatment. CONCLUSION We have proposed measures that are simple to carry out for the main types of drug that can interact with ritonavir. These measures can be implemented under quarantine conditions before starting a 5-day treatment with nirmatrelvir/r.
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Affiliation(s)
- Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kathrin I. Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Theresa Terstegen
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Cathrin Vogt
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - André Said
- Drug Commission of German Pharmacists (AMK), Berlin, Germany
| | - Martin Schulz
- Drug Commission of German Pharmacists (AMK), Berlin, Germany
- Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany: Prof. Dr. rer. nat. Martin Schulz
| | - Walter E. Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- *Abteilung Klinische Pharmakologie und Pharmakoepidemiologie Universitätsklinikum Heidelberg Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
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Nassar YM, Hohmann N, Michelet R, Gottwalt K, Meid AD, Burhenne J, Huisinga W, Haefeli WE, Mikus G, Kloft C. Quantification of the Time Course of CYP3A Inhibition, Activation, and Induction Using a Population Pharmacokinetic Model of Microdosed Midazolam Continuous Infusion. Clin Pharmacokinet 2022; 61:1595-1607. [PMID: 36195807 PMCID: PMC9652212 DOI: 10.1007/s40262-022-01175-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cytochrome P450 (CYP) 3A contributes to the metabolism of many approved drugs. CYP3A perpetrator drugs can profoundly alter the exposure of CYP3A substrates. However, effects of such drug-drug interactions are usually reported as maximum effects rather than studied as time-dependent processes. Identification of the time course of CYP3A modulation can provide insight into when significant changes to CYP3A activity occurs, help better design drug-drug interaction studies, and manage drug-drug interactions in clinical practice. OBJECTIVE We aimed to quantify the time course and extent of the in vivo modulation of different CYP3A perpetrator drugs on hepatic CYP3A activity and distinguish different modulatory mechanisms by their time of onset, using pharmacologically inactive intravenous microgram doses of the CYP3A-specific substrate midazolam, as a marker of CYP3A activity. METHODS Twenty-four healthy individuals received an intravenous midazolam bolus followed by a continuous infusion for 10 or 36 h. Individuals were randomized into four arms: within each arm, two individuals served as a placebo control and, 2 h after start of the midazolam infusion, four individuals received the CYP3A perpetrator drug: voriconazole (inhibitor, orally or intravenously), rifampicin (inducer, orally), or efavirenz (activator, orally). After midazolam bolus administration, blood samples were taken every hour (rifampicin arm) or every 15 min (remaining study arms) until the end of midazolam infusion. A total of 1858 concentrations were equally divided between midazolam and its metabolite, 1'-hydroxymidazolam. A nonlinear mixed-effects population pharmacokinetic model of both compounds was developed using NONMEM®. CYP3A activity modulation was quantified over time, as the relative change of midazolam clearance encountered by the perpetrator drug, compared to the corresponding clearance value in the placebo arm. RESULTS Time course of CYP3A modulation and magnitude of maximum effect were identified for each perpetrator drug. While efavirenz CYP3A activation was relatively fast and short, reaching a maximum after approximately 2-3 h, the induction effect of rifampicin could only be observed after 22 h, with a maximum after approximately 28-30 h followed by a steep drop to almost baseline within 1-2 h. In contrast, the inhibitory impact of both oral and intravenous voriconazole was prolonged with a steady inhibition of CYP3A activity followed by a gradual increase in the inhibitory effect until the end of sampling at 8 h. Relative maximum clearance changes were +59.1%, +46.7%, -70.6%, and -61.1% for efavirenz, rifampicin, oral voriconazole, and intravenous voriconazole, respectively. CONCLUSIONS We could distinguish between different mechanisms of CYP3A modulation by the time of onset. Identification of the time at which clearance significantly changes, per perpetrator drug, can guide the design of an optimal sampling schedule for future drug-drug interaction studies. The impact of a short-term combination of different perpetrator drugs on the paradigm CYP3A substrate midazolam was characterized and can define combination intervals in which no relevant interaction is to be expected. CLINICAL TRIAL REGISTRATION The trial was registered at the European Union Drug Regulating Authorities for Clinical Trials (EudraCT-No. 2013-004869-14).
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Affiliation(s)
- Yomna M. Nassar
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany ,grid.14095.390000 0000 9116 4836Graduate Research Training Program PharMetrX, Freie Universität Berlin/University of Potsdam, Berlin/Potsdam, Germany
| | - Nicolas Hohmann
- grid.7700.00000 0001 2190 4373Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Robin Michelet
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany
| | - Katharina Gottwalt
- grid.7700.00000 0001 2190 4373Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Andreas D. Meid
- grid.7700.00000 0001 2190 4373Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Jürgen Burhenne
- grid.7700.00000 0001 2190 4373Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Wilhelm Huisinga
- grid.11348.3f0000 0001 0942 1117Institute of Mathematics, University of Potsdam, Potsdam, Germany
| | - Walter E. Haefeli
- grid.7700.00000 0001 2190 4373Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Gerd Mikus
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany ,grid.7700.00000 0001 2190 4373Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Charlotte Kloft
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany
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Hu W, Lettiere D, Tse S, Johnson TR, Biddle KE, Thibault S, Palazzi X, Chen J, Pithavala YK, Finkelstein M. Liver Toxicity Observed With Lorlatinib When Combined With Strong CYP3A Inducers: Evaluation of Cynomolgus Monkey as a Nonclinical Model for Assessing the Mechanism of Combinational Toxicity. Toxicol Sci 2021; 182:183-194. [PMID: 34021354 DOI: 10.1093/toxsci/kfab056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Lorlatinib is a potent small-molecule anaplastic lymphoma kinase inhibitor approved for the treatment of patients with nonsmall cell lung cancer. In a drug-drug interaction study in healthy human participants, liver enzyme elevations were observed when a single 100 mg dose of lorlatinib was administered after multiple doses of rifampin, a strong cytochrome P450 (CYP) 3A inducer and a pregnane X receptor (PXR) agonist. A series of in vitro and in vivo studies were conducted to evaluate potential mechanisms for the observed clinical toxicity. To investigate the involvement of CYP3A and/or PXR in the observed liver toxicity, studies were conducted in cynomolgus monkeys administered lorlatinib alone or with coadministration of multiple doses of known CYP3A inducers that are predominantly PXR agonists (rifampin, St. John's wort) or predominantly constitutive androstane receptor agonists (carbamazepine, phenytoin) and a net CYP3A inhibitory PXR agonist (ritonavir). Results from the investigative studies identified cynomolgus monkeys as a pharmacologically relevant nonclinical model, which recapitulated the elevated liver function test results observed in humans. Furthermore, liver toxicity was only observed in this model when lorlatinib was coadministered with strong CYP3A inducers, and the effects were not restricted to, or exclusively dependent upon, a PXR activation mechanism. These results generated mechanistic insights on the liver enzyme elevations observed in the clinical drug-drug interaction study and provided guidance on appropriate product safety label for lorlatinib.
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Affiliation(s)
- Wenyue Hu
- Drug Safety Research and Development, Pfizer Inc, San Diego, California 92121, USA
| | - Daniel Lettiere
- Drug Safety Research and Development, Dynamics & Metabolism, Pfizer Inc, Groton, Connecticut 06340, USA
| | - Susanna Tse
- Pharmacokinetics, Dynamics & Metabolism, Pfizer Inc, Groton, Connecticut 06340, USA
| | - Theodore R Johnson
- Pharmacokinetics, Dynamics & Metabolism, San Diego, California 92121, USA
| | - Kathleen E Biddle
- Drug Safety Research and Development, Dynamics & Metabolism, Pfizer Inc, Groton, Connecticut 06340, USA
| | - Stephane Thibault
- Drug Safety Research and Development, Pfizer Inc, San Diego, California 92121, USA
| | - Xavier Palazzi
- Drug Safety Research and Development, Dynamics & Metabolism, Pfizer Inc, Groton, Connecticut 06340, USA
| | - Joseph Chen
- Clinical Pharmacology, Pfizer Inc, San Diego, California 92121, USA
| | | | - Martin Finkelstein
- Drug Safety Research and Development, Pfizer Inc, San Diego, California 92121, USA
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Vermunt M, Marchetti S, Beijnen J. Pharmacokinetics and Toxicities of Oral Docetaxel Formulations Co-Administered with Ritonavir in Phase I Trials. Clin Pharmacol 2021; 13:21-32. [PMID: 33536797 PMCID: PMC7850405 DOI: 10.2147/cpaa.s292746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/06/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction Docetaxel is widely used as intravenous (IV) chemotherapy. Oral docetaxel is co-administered with the cytochrome P450 3A4 and P-glycoprotein inhibitor ritonavir to increase oral bioavailability. This research explores the relationship between the pharmacokinetics (PK) and toxicity of this novel oral chemotherapy. Methods The patients in two phase I trials were treated with different oral docetaxel formulations in combination with ritonavir in different dose levels, ranging from 20 to 80 mg docetaxel with 100 to 200 mg ritonavir a day. The patients were categorized based on the absence or occurrence of severe treatment-related toxicity (grade ≥3 or any grade leading to treatment alterations). The docetaxel area under the plasma concentration–time curve (AUC) and maximum plasma concentration (Cmax) were associated with toxicity. Results Thirty-four out of 138 patients experienced severe toxicity, most frequently observed as mucositis, fatigue, diarrhea, nausea and vomiting. The severe toxicity group had a significantly higher docetaxel AUC (2231 ± 1405 vs 1011 ± 830 ng/mL*h, p<0.0001) and Cmax (218 ± 178 vs 119 ± 77 ng/mL, p<0.0001) as compared to the patients without severe toxicity. When extrapolated from IV PK data, the patients without severe toxicity had a similar cumulative docetaxel AUC as with standard 3-weekly IV docetaxel, while the Cmax was up to 10-fold lower with oral docetaxel and ritonavir. Conclusion Severe toxicity was observed in 25% of the patients treated with oral docetaxel and ritonavir. This toxicity seems related to the PK, as the docetaxel AUC0-inf and Cmax were up to twofold higher in the severe toxicity group as compared to the non-severe toxicity group. Future randomized trials will provide a further evaluation of the toxicity and efficacy of the new weekly oral docetaxel and ritonavir regimen in comparison to standard IV docetaxel.
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Affiliation(s)
- Marit Vermunt
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam 1066, CX, the Netherlands
| | - Serena Marchetti
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam 1066, CX, the Netherlands
| | - Jos Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute, Amsterdam 1066, CX, the Netherlands.,Modra Pharmaceuticals B.V., Amsterdam 1083, HN, the Netherlands.,Department of Pharmaceutical Sciences, Utrecht University, Utrecht 3584, CX, the Netherlands
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Clinically Significant Drug Interactions Between Psychotropic Agents and Repurposed COVID-19 Therapies. CNS Drugs 2021; 35:345-384. [PMID: 33866523 PMCID: PMC8053373 DOI: 10.1007/s40263-021-00811-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2021] [Indexed: 02/07/2023]
Abstract
As many patients with underlying psychiatric disorders may be infected with COVID-19, and COVID-19-affected subjects may frequently experience a new onset of psychiatric manifestations, concomitant use of psychotropic medications and COVID-19 therapies is expected to be highly likely and raises concerns of clinically relevant drug interactions. In this setting, four major mechanisms responsible for drug interactions involving psychotropic agents and COVID-19 therapies may be identified: (1) pharmacokinetic drug-drug interactions mainly acting on cytochrome P450; (2) pharmacodynamic drug-drug interactions resulting in additive or synergistic toxicity; (3) drug-disease interactions according to stage and severity of the disease; and (4) pharmacogenetic issues associated with polymorphisms of cytochrome P450 isoenzymes. In this review, we summarise the available literature on relevant drug interactions between psychotropic agents and COVID-19 therapies, providing practical clinical recommendations and potential management strategies according to severity of illness and clinical scenario.
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Effect of Systemic Inflammatory Response to SARS-CoV-2 on Lopinavir and Hydroxychloroquine Plasma Concentrations. Antimicrob Agents Chemother 2020; 64:AAC.01177-20. [PMID: 32641296 PMCID: PMC7449226 DOI: 10.1128/aac.01177-20] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/06/2020] [Indexed: 12/17/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) leads to inflammatory cytokine release, which can downregulate the expression of metabolizing enzymes. This cascade affects drug concentrations in the plasma. We investigated the association between lopinavir (LPV) and hydroxychloroquine (HCQ) plasma concentrations and the levels of the acute-phase inflammation marker C-reactive protein (CRP). LPV plasma concentrations in 92 patients hospitalized at our institution were prospectively collected. Lopinavir-ritonavir was administered every 12 hours, 800/200 mg on day 1 and 400/100 mg on day 2 until day 5 or 7. HCQ was given at 800 mg, followed by 400 mg after 6, 24, and 48 h. Hematological, liver, kidney, and inflammation laboratory values were analyzed on the day of drug level determination. The median age of study participants was 59 (range, 24 to 85) years, and 71% were male. The median durations from symptom onset to hospitalization and treatment initiation were 7 days (interquartile range [IQR], 4 to 10) and 8 days (IQR, 5 to 10), respectively. The median LPV trough concentration on day 3 of treatment was 26.5 μg/ml (IQR, 18.9 to 31.5). LPV plasma concentrations positively correlated with CRP values (r = 0.37, P < 0.001) and were significantly lower when tocilizumab was preadministered. No correlation was found between HCQ concentrations and CRP values. High LPV plasma concentrations were observed in COVID-19 patients. The ratio of calculated unbound drug fraction to published SARS-CoV-2 50% effective concentrations (EC50) indicated insufficient LPV concentrations in the lung. CRP values significantly correlated with LPV but not HCQ plasma concentrations, implying inhibition of cytochrome P450 3A4 (CYP3A4) metabolism by inflammation.
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Composite midazolam and 1'-OH midazolam population pharmacokinetic model for constitutive, inhibited and induced CYP3A activity. J Pharmacokinet Pharmacodyn 2020; 47:527-542. [PMID: 32772302 PMCID: PMC7652802 DOI: 10.1007/s10928-020-09704-1] [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: 03/06/2020] [Accepted: 07/12/2020] [Indexed: 11/17/2022]
Abstract
CYP3A plays an important role in drug metabolism and, thus, can be a considerable liability for drug-drug interactions. Population pharmacokinetics may be an efficient tool for detecting such drug-drug interactions. Multiple models have been developed for midazolam, the typical probe substrate for CYP3A activity, but no population pharmacokinetic models have been developed for use with inhibition or induction. The objective of the current analysis was to develop a composite parent-metabolite model for midazolam which could adequately describe CYP3A drug-drug interactions. As an exploratory objective, parameters were assessed for potential cut-points which may allow for determination of drug-drug interactions when a baseline profile is not available. The final interaction model adequately described midazolam and 1′-OH midazolam concentrations for constitutive, inhibited, and induced CYP3A activity. The model showed good internal and external validity, both with full profiles and limited sampling (2, 2.5, 3, and 4 h), and the model predicted parameters were congruent with values found in clinical studies. Assessment of potential cut-points for model predicted parameters to assess drug-drug interaction liability with a single profile suggested that midazolam clearance may reasonably be used to detect inhibition (4.82–16.4 L/h), induction (41.8–88.9 L/h), and no modulation (16.4–41.8 L/h), with sensitivities for potent inhibition and induction of 87.9% and 83.3%, respectively, and a specificity of 98.2% for no modulation. Thus, the current model and cut-points could provide efficient and accurate tools for drug-drug liability detection, both during drug development and in the clinic, following prospective validation in healthy volunteers and patient populations.
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Mikus G, Foerster KI, Schaumaeker M, Lehmann M, Burhenne J, Haefeli WE. Application of a microdosed cocktail of 3 oral factor Xa inhibitors to study drug-drug interactions with different perpetrator drugs. Br J Clin Pharmacol 2020; 86:1632-1641. [PMID: 32159869 PMCID: PMC7373712 DOI: 10.1111/bcp.14277] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/20/2020] [Accepted: 03/03/2020] [Indexed: 12/13/2022] Open
Abstract
AIMS Using 3 different perpetrators the impact of voriconazole, cobicistat and rifampicin (single dose), we evaluated the suitability of a microdose cocktail of factor Xa inhibitors (FXaI; rivaroxaban, apixaban and edoxaban; 100 μg in total) to study drug-drug interactions. METHODS Three cohorts of 6 healthy volunteers received 2 treatments with microdoses of rivaroxaban, apixaban and edoxaban alone and with coadministration of 1 of the perpetrators. Plasma and urine concentrations of microdosed apixaban, edoxaban and rivaroxaban were quantified using a validated ultra-performance liquid chromatography-tandem mass spectrometry with a lower limit of quantification of 2.5 pg/mL. RESULTS Voriconazole caused only a minor interaction with apixaban and rivaroxaban, none with edoxaban. Cobicistat significantly increased exposure of all 3 FXaI with area under the plasma concentration-time curve ratios of 1.67 (apixaban), 1.74 (edoxaban) and 2.0 (rivaroxaban). A single dose of rifampicin decreased the volume of distribution and elimination half-life of all 3 FXaI. CONCLUSIONS The microdosed FXaI cocktail approach is able to generate drug interaction data and can help elucidating the mechanism involved in the clearance of the different victim drugs. This is a safe approach to concurrently study drug-drug interactions with a drug class. (EudraCT 2016-003024-23).
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Affiliation(s)
- Gerd Mikus
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Kathrin I. Foerster
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Marlene Schaumaeker
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Marie‐Louise Lehmann
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Walter E. Haefeli
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
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Yu H, Janssen JM, Sawicki E, van Hasselt JGC, de Weger VA, Nuijen B, Schellens JHM, Beijnen JH, Huitema ADR. A Population Pharmacokinetic Model of Oral Docetaxel Coadministered With Ritonavir to Support Early Clinical Development. J Clin Pharmacol 2019; 60:340-350. [PMID: 31595980 DOI: 10.1002/jcph.1532] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/20/2019] [Indexed: 11/08/2022]
Abstract
Oral administration of docetaxel is an attractive alternative for conventional intravenous (IV) administration. The low bioavailability of docetaxel, however, hinders the application of oral docetaxel in the clinic. The aim of the current study was to develop a population pharmacokinetic (PK) model for docetaxel and ritonavir based on the phase 1 studies and to support drug development of this combination treatment. PK data were collected from 191 patients who received IV docetaxel and different oral docetaxel formulations (drinking solution, ModraDoc001 capsule, and ModraDoc006 tablet) coadministered with ritonavir. A PK model was first developed for ritonavir. Subsequently, a semiphysiological PK model was developed for docetaxel, which incorporated the inhibition of docetaxel metabolism by ritonavir. The uninhibited intrinsic clearance of docetaxel was estimated based on data on IV docetaxel as 1980 L/h (relative standard error, 11%). Ritonavir coadministration extensively inhibited the hepatic metabolism of docetaxel to 9.3%, which resulted in up to 12-fold higher docetaxel plasma concentrations compared to oral docetaxel coadministered without ritonavir. In conclusion, a semiphysiological PK model for docetaxel and ritonavir was successfully developed. Coadministration of ritonavir resulted in increased plasma concentrations of docetaxel after administration of the oral formulations of ModraDoc. Furthermore, the oral ModraDoc formulations showed lower variability in plasma concentrations between and within patients compared to the drinking solution. Comparable exposure could be reached with the oral ModraDoc formulations compared to IV administration.
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Affiliation(s)
- Huixin Yu
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Julie M Janssen
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Emilia Sawicki
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - J G Coen van Hasselt
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Vincent A de Weger
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Bastiaan Nuijen
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Jan H M Schellens
- Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Utrecht Institute of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Hohmann N, Blank A, Burhenne J, Suzuki Y, Mikus G, Haefeli WE. Simultaneous phenotyping of CYP2E1 and CYP3A using oral chlorzoxazone and midazolam microdoses. Br J Clin Pharmacol 2019; 85:2310-2320. [PMID: 31222796 DOI: 10.1111/bcp.14040] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 05/31/2019] [Accepted: 06/10/2019] [Indexed: 12/24/2022] Open
Abstract
AIMS Chlorzoxazone is the paradigm marker substrate for CYP2E1 phenotyping in vivo. Because at the commonly used milligram doses (250-750 mg) chlorzoxazone acts as an inhibitor of the CYP3A4/5 marker substrate midazolam, previous attempts failed to combine both drugs in a common phenotyping cocktail. Microdosing chlorzoxazone could circumvent this problem. METHOD We enrolled 12 healthy volunteers in a trial investigating the dose-exposure relationship of single ascending chlorzoxazone oral doses over a 10,000-fold range (0.05-500 mg) and assessed the effect of 0.1 and 500 mg of chlorzoxazone on oral midazolam pharmacokinetics (0.003 mg). RESULTS Chlorzoxazone area under the concentration-time curve was dose-linear in the dose range between 0.05 and 5 mg. A nonlinear increase occurred with doses ≥50 mg, probably due to saturated presystemic metabolic elimination. While midazolam area under the concentration-time curve increased 2-fold when coadministered with 500 mg of chlorzoxazone, there was no pharmacokinetic interaction between chlorzoxazone and midazolam microdoses. CONCLUSION The chlorzoxazone microdose did not interact with the CYP3A marker substrate midazolam, enabling the simultaneous administration in a phenotyping cocktail. This microdose assay is now ready to be further validated and tested as a phenotyping procedure assessing the impact of induction and inhibition of CYP2E1 on chlorzoxazone microdose pharmacokinetics.
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Affiliation(s)
- Nicolas Hohmann
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Germany
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Germany
| | - Yosuke Suzuki
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Germany
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24
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Greenblatt DJ, Mikus G. Ketoconazole and Liver Injury: A Five-Year Update. Clin Pharmacol Drug Dev 2019; 8:6-8. [DOI: 10.1002/cpdd.652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology; University of Heidelberg; Heidelberg Germany
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25
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Sampson MR, Cao KY, Gish PL, Hyon K, Mishra P, Tauber W, Zhao P, Zhou EH, Younis IR. Dosing Recommendations for Quetiapine When Coadministered With HIV Protease Inhibitors. J Clin Pharmacol 2018; 59:500-509. [DOI: 10.1002/jcph.1345] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/31/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Mario R. Sampson
- Office of Clinical Pharmacology, Office of Translational Sciences; Center for Drug Evaluation and Review, Food and Drug Administration; Silver Spring MD USA
| | - Kelly Y. Cao
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology; Center for Drug Evaluation and Research, Food and Drug Administration; Silver Spring MD USA
| | - Paula L. Gish
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology; Center for Drug Evaluation and Research, Food and Drug Administration; Silver Spring MD USA
| | - Kyong Hyon
- Division of Antiviral Products, Office of Antimicrobial Products, Office of New Drugs; Center for Drug Evaluation and Research, Food and Drug Administration; Silver Spring MD USA
| | - Poonam Mishra
- Division of Antiviral Products, Office of Antimicrobial Products, Office of New Drugs; Center for Drug Evaluation and Research, Food and Drug Administration; Silver Spring MD USA
| | - William Tauber
- Division of Antiviral Products, Office of Antimicrobial Products, Office of New Drugs; Center for Drug Evaluation and Research, Food and Drug Administration; Silver Spring MD USA
| | - Ping Zhao
- Office of Clinical Pharmacology, Office of Translational Sciences; Center for Drug Evaluation and Review, Food and Drug Administration; Silver Spring MD USA
| | - Esther H. Zhou
- Office of Pharmacovigilance and Epidemiology, Office of Surveillance and Epidemiology; Center for Drug Evaluation and Research, Food and Drug Administration; Silver Spring MD USA
| | - Islam R. Younis
- Office of Clinical Pharmacology, Office of Translational Sciences; Center for Drug Evaluation and Review, Food and Drug Administration; Silver Spring MD USA
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Uvarova NE, Eremenko NN, Ramenskaya GV, Goryachev DV. Planning and Assessment of Bioequivalence Studies of Darunavir Preparations. Pharm Chem J 2018. [DOI: 10.1007/s11094-018-1897-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Umehara KI, Huth F, Won CS, Heimbach T, He H. Verification of a physiologically based pharmacokinetic model of ritonavir to estimate drug-drug interaction potential of CYP3A4 substrates. Biopharm Drug Dispos 2018; 39:152-163. [DOI: 10.1002/bdd.2122] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 02/06/2018] [Accepted: 02/07/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Ken-ichi Umehara
- PK Sciences, Novartis Institutes for BioMedical Research; CH-4002 Basel Switzerland
| | - Felix Huth
- PK Sciences, Novartis Institutes for BioMedical Research; CH-4002 Basel Switzerland
| | - Christina S. Won
- PK Sciences, Novartis Institutes for BioMedical Research; East Hanover NJ 07936 USA
| | - Tycho Heimbach
- PK Sciences, Novartis Institutes for BioMedical Research; East Hanover NJ 07936 USA
| | - Handan He
- PK Sciences, Novartis Institutes for BioMedical Research; East Hanover NJ 07936 USA
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28
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Freise KJ, Hu B, Salem AH. Impact of ritonavir dose and schedule on CYP3A inhibition and venetoclax clinical pharmacokinetics. Eur J Clin Pharmacol 2018; 74:413-421. [PMID: 29302721 DOI: 10.1007/s00228-017-2403-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 12/11/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE Venetoclax is a selective BCL-2 inhibitor indicated for the treatment of patients with chronic lymphocytic leukemia (CLL). It is predominately metabolized by cytochrome P450 (CYP) 3A. The study objective was to determine the effect of different dosage regimens of ritonavir, a strong CYP3A inhibitor, on the pharmacokinetics of venetoclax in 20 healthy subjects. METHODS In cohorts 1 and 2, subjects received single 10 mg doses of venetoclax in periods 1 and 2 and a single 50- or 100-mg dose of ritonavir in period 2. In cohort 3, subjects received 10-mg venetoclax doses on day 1 of period 1 and days 1 and 11 of period 2, and 50 mg ritonavir daily on days 1 to 14 of period 2. RESULTS Single doses of 50 and 100 mg ritonavir increased the venetoclax maximum concentration (Cmax) 2.3- to 2.4-fold compared to venetoclax alone and the area under the curve (AUC) 6.1- and 8.1-fold, respectively. Daily 50 mg ritonavir resulted in a 2.4- and 7.9-fold increase in venetoclax Cmax and AUC, respectively. Administration of 50 mg ritonavir daily saturated CYP3A inhibition and completely inhibited the formation of the major venetoclax metabolite M27. Time-dependent CYP3A inhibition with daily 50 mg ritonavir was offset by ritonavir CYP3A induction, resulting in a limited net increase in CYP3A inhibition with multiple doses. CONCLUSION After completion of the dose ramp-up, venetoclax dose reductions of at least 75% are recommended when administered concomitantly with strong CYP3A inhibitors to maintain venetoclax exposures within the established therapeutic window for CLL treatment.
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Affiliation(s)
- Kevin J Freise
- AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Beibei Hu
- AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Ahmed Hamed Salem
- AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA. .,Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt.
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Hossain MA, Tran T, Chen T, Mikus G, Greenblatt DJ. Inhibition of human cytochromes P450 in vitro by ritonavir and cobicistat. J Pharm Pharmacol 2017; 69:1786-1793. [PMID: 28960344 DOI: 10.1111/jphp.12820] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 08/26/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Ritonavir and cobicistat are strong inhibitors of human cytochrome P450-3A (CYP3A) isoforms, and are used clinically as pharmacokinetic boosting agents for other antiretroviral drugs. Data reported by the manufacturer suggest that cobicistat is a more selective inhibitor of CYP3A than ritonavir. However, this claim has not been validated in clinical studies. This study evaluated the in-vitro inhibitory potency of ritonavir and cobicistat vs a series of human CYP isoforms. METHOD The model system utilized human liver microsomes and isoform-selective index substrates. KEY FINDINGS Ritonavir and cobicistat both were strong inhibitors of CYP3A4, with IC50 values of 0.014 and 0.032 μm, respectively. A component of inhibition was time-dependent (mechanism-based). Neither drug meaningfully inhibited CYP1A2 (IC50 > 150 μm). CYP2B6, CYP2C9, CYP2C19 and CYP2D6 were inhibited by both drugs, but with IC50 values exceeding 6 μm. CONCLUSIONS Consistent with previous reports, both ritonavir and cobicistat were highly potent inhibitors of CYP3A. Both drugs were weaker inhibitors of other human CYPs, with IC50 values at least two orders of magnitude higher. There was no evidence of a meaningful difference in selectivity between the two drugs.
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Affiliation(s)
- Md Amin Hossain
- Graduate Program in Pharmacology and Drug Development, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
| | - Timothy Tran
- Graduate Program in Pharmacology and Drug Development, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
| | - Tianmeng Chen
- Graduate Program in Pharmacology and Drug Development, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - David J Greenblatt
- Graduate Program in Pharmacology and Drug Development, Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, USA.,Department of Integrative Physiology and Pathobiology, Tufts University School of Medicine, Boston, MA, USA
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Algeelani S, Alam N, Hossain MA, Mikus G, Greenblatt DJ. In vitro inhibition of human UGT isoforms by ritonavir and cobicistat. Xenobiotica 2017; 48:764-769. [PMID: 28891378 DOI: 10.1080/00498254.2017.1370655] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
1. Ritonavir and cobicistat are pharmacokinetic boosting agents used to increase systemic exposure to other antiretroviral therapies. The manufacturer's data suggests that cobicistat is a more selective CYP3A4 inhibitor than ritonavir. However, the inhibitory effect of ritonavir and cobicistat on human UDP glucuronosyltransferase (UGT) enzymes in Phase II metabolism is not established. This study evaluated the inhibition of human UGT isoforms by ritonavir versus cobicistat. 2. Acetaminophen and ibuprofen were used as substrates to evaluate the metabolic activity of the principal human UGTs. Metabolite formation rates were determined by HPLC analysis of incubates following in vitro incubation of index substrates with human liver microsomes (HLMs) at different concentrations of ritonavir or cobicistat. Probenecid and estradiol served as positive control inhibitors. 3. The 50% inhibitory concentrations (IC50) of cobicistat and ritonavir were at least 50 µM, which substantially exceeds usual clinical plasma concentrations. Probenecid inhibited the glucuronidation of acetaminophen (IC50 0.7 mM), but not glucuronidation of ibuprofen. At relatively high concentrations, estradiol inhibited ibuprofen glucuronidation (IC50 17 µM). 4. Ritonavir and cobicistat are unlikely to produce clinically important drug interactions involving drugs metabolized to glucuronide conjugates by UGT1A1, 1A3, 1A6, 1A9, 2B4 and 2B7.
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Affiliation(s)
- Sara Algeelani
- a Graduate Program in Pharmacology and Drug Development, Sackler School of Graduate Biomedical Sciences , Boston , MA , USA
| | - Novera Alam
- a Graduate Program in Pharmacology and Drug Development, Sackler School of Graduate Biomedical Sciences , Boston , MA , USA
| | - Md Amin Hossain
- a Graduate Program in Pharmacology and Drug Development, Sackler School of Graduate Biomedical Sciences , Boston , MA , USA
| | - Gerd Mikus
- b Department of Clinical Pharmacology and Pharmacoepidemiology , University of Heidelberg , Heidelberg , Germany , and
| | - David J Greenblatt
- a Graduate Program in Pharmacology and Drug Development, Sackler School of Graduate Biomedical Sciences , Boston , MA , USA.,c Department of Integrative Physiology and Pathobiology , Tufts University School of Medicine , Boston , MA , USA
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Weinheimer M, Fricker G, Burhenne J, Mylius P, Schubert R. The application of P-gp inhibiting phospholipids as novel oral bioavailability enhancers - An in vitro and in vivo comparison. Eur J Pharm Sci 2016; 108:13-22. [PMID: 27590127 DOI: 10.1016/j.ejps.2016.08.055] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 07/14/2016] [Accepted: 08/29/2016] [Indexed: 01/11/2023]
Abstract
The efflux transporter P-glycoprotein (P-gp) significantly modulates drug transport across the intestinal mucosa, strongly reducing the systemic absorption of various active pharmaceutical ingredients. P-gp inhibitors could serve as helpful tools to enhance the oral bioavailability of those substances. As a membrane-associated protein P-gp is surrounded and influenced by phospholipids. Some synthetic phospholipids have been found to strongly reduce P-gp's activity. In this study two representative phospholipids, 1,2-dioctanoyl-sn-glycero-3-phosphocholine (8:0 PC) and 1,2-didecanoyl-sn-glycero-3-phosphocholine (10:0 PC), were compared with Tween® 80 and Cremophor® EL, both commonly used surfactants with P-gp inhibitory properties. Their influence on the cellular transport of the P-gp substrate rhodamine 123 (RH123) was examined using Caco-2 cell layers. In addition, fluorescence anisotropy measurements were performed in order to investigate their effect on membrane fluidity. Finally, we compared the phospholipids with Tween® 80 and the competitive P-gp inhibitor verapamil in an in vivo study, testing their effects on the oral bioavailability of the P-gp substrate drug ritonavir. Both phospholipids not only led to the strongest absorption of RH123, but a permeability enhancing effect was detected in addition to the P-gp inhibition. Their effects on membrane fluidity were not consistent with their P-gp inhibiting effects, and therefore suggested a more complex mode of action. Both phospholipids significantly increased the area under the ritonavir plasma level curve (AUC) within 150min by more than tenfold, but were inferior to Tween® 80, which showed superior solubilizing effects. Finally, these phospholipids represent a novel substance class showing a high permeabilization potential for P-gp substrates. Because of their physiological structure and intestinal degradability, good tolerability without systemic absorption is expected. Formulating P-gp substrates with an originally low oral bioavailability is a difficult task, requiring concerted interplay of all excipients. P-gp inhibiting phospholipids offer a new tool to help cope with these challenges.
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Affiliation(s)
- Manuel Weinheimer
- Department of Pharmaceutical Technology and Biopharmacy, Albert Ludwig University Freiburg, Hermann-Herder-Str. 9, D-79104 Freiburg, Germany.
| | - Gert Fricker
- Institute of Pharmacy and Molecular Biotechnology, University of Heidelberg, Im Neuheimer Feld 329, D-69120 Heidelberg, Germany.
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, D-69120, Heidelberg, Germany.
| | - Patricia Mylius
- Department of Pharmaceutical Technology and Biopharmacy, Albert Ludwig University Freiburg, Hermann-Herder-Str. 9, D-79104 Freiburg, Germany
| | - Rolf Schubert
- Department of Pharmaceutical Technology and Biopharmacy, Albert Ludwig University Freiburg, Hermann-Herder-Str. 9, D-79104 Freiburg, Germany.
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Hohmann N, Kocheise F, Carls A, Burhenne J, Weiss J, Haefeli WE, Mikus G. Dose-Dependent Bioavailability and CYP3A Inhibition Contribute to Non-Linear Pharmacokinetics of Voriconazole. Clin Pharmacokinet 2016; 55:1535-1545. [DOI: 10.1007/s40262-016-0416-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Greenblatt DJ. Evidence-based choice of ritonavir as index CYP3A inhibitor in drug-drug interaction studies. J Clin Pharmacol 2015; 56:152-6. [PMID: 26239522 DOI: 10.1002/jcph.609] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 07/31/2015] [Indexed: 12/23/2022]
Affiliation(s)
- David J Greenblatt
- Program in Pharmacology and Experimental Therapeutics, Tufts University School of Medicine and Tufts Medical Center, Boston, MA, USA
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Keemink J, Augustijns P, Annaert P. Unbound Ritonavir Concentrations in Rat and Human Hepatocytes. J Pharm Sci 2015; 104:2378-87. [DOI: 10.1002/jps.24477] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/16/2015] [Accepted: 04/16/2015] [Indexed: 12/17/2022]
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Greenblatt DJ, Harmatz JS. Ritonavir is the best alternative to ketoconazole as an index inhibitor of cytochrome P450-3A in drug-drug interaction studies. Br J Clin Pharmacol 2015; 80:342-50. [PMID: 25923589 DOI: 10.1111/bcp.12668] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 04/23/2015] [Accepted: 04/24/2015] [Indexed: 12/16/2022] Open
Abstract
AIMS The regulatory prohibition of ketoconazole as a CYP3A index inhibitor in drug-drug interaction (DDI) studies has compelled consideration of alternative inhibitors. METHODS The biomedical literature was searched to identify DDI studies in which oral midazolam (MDZ) was the victim, and the inhibitory perpetrator was either ketoconazole, itraconazole, clarithromycin, or ritonavir. The ratios (RAUC ) of total area under the curve (AUC) for MDZ with inhibitor divided by MDZ AUC in the control condition were aggregated across individual studies for each inhibitor. RESULTS Mean (± SE) RAUC values were: ketoconazole (15 studies, 131 subjects), 11.5 (±1.2); itraconazole (five studies, 48 subjects), 7.3 (±1.0); clarithromycin (five studies, 73 subjects), 6.5 (±10.9); and ritonavir (13 studies, 159 subjects), 14.5 (±2.0). Differences among inhibitors were significant (F = 5.31, P < 0.005). RAUC values were not significantly related to inhibitor dosage or to duration of inhibitor pre-exposure prior to administration of MDZ. CONCLUSIONS Ritonavir produces CYP3A inhibition equivalent to or greater than ketoconazole, and is the best index CYP3A inhibitor alternative to ketoconazole. Cobicistat closely resembles ritonavir in structure and function, and can also be considered. Itraconazole and clarithromycin are not suitable alternatives since they do not produce inhibition comparable with ketoconazole or ritonavir, and have other significant disadvantages as well.
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Affiliation(s)
- David J Greenblatt
- From the Program in Pharmacology and Experimental Therapeutics, Tufts University School of Medicine and Sackler School of Graduate Biomedical Sciences, Boston, MA, USA
| | - Jerold S Harmatz
- From the Program in Pharmacology and Experimental Therapeutics, Tufts University School of Medicine and Sackler School of Graduate Biomedical Sciences, Boston, MA, USA
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Wurz GT, DeGregorio MW. Response to: “Deceptive argumentation against diagnostic microdosing of anticancer drugs” by Dirk Theile and Gerd Mikus (Letter dated February 13, 2014). Int J Cancer 2014; 135:1751-2. [DOI: 10.1002/ijc.28805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 02/20/2014] [Indexed: 11/12/2022]
Affiliation(s)
- Gregory T. Wurz
- Division of Hematology and Oncology; Department of Internal Medicine; University of California; Davis, Sacramento CA 95817
| | - Michael W. DeGregorio
- Division of Hematology and Oncology; Department of Internal Medicine; University of California; Davis, Sacramento CA 95817
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Theile D, Mikus G. Deceptive argumentation against diagnostic microdosing of anticancer drugs. Int J Cancer 2014; 135:1753-4. [PMID: 24615734 DOI: 10.1002/ijc.28806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 02/20/2014] [Indexed: 11/05/2022]
Affiliation(s)
- Dirk Theile
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, D-69120, Heidelberg, Germany
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