Liver function tests and low-dose estrogen oral contraceptives

Effect of Oral Semaglutide on the Pharmacokinetics of Levonorgestrel and Ethinylestradiol in Healthy Postmenopausal Women and Furosemide and Rosuvastatin in Healthy Subjects

Background

The first oral glucagon-like peptide-1 receptor agonist (GLP-1RA) comprises semaglutide co-formulated with the absorption enhancer, sodium N-(8-[2-hydroxybenzoyl] amino) caprylate (SNAC). Oral semaglutide may alter the pharmacokinetics of co-administered drugs via effects of semaglutide or SNAC. Two separate one-sequence crossover trials investigated the effects of oral semaglutide and SNAC on the pharmacokinetics of ethinylestradiol, levonorgestrel, furosemide and rosuvastatin.

Methods

Healthy, postmenopausal women (n = 25) received once-daily combined ethinylestradiol and levonorgestrel (Trial 1) and healthy male and female subjects (n = 41) received single doses of furosemide and rosuvastatin (Trial 2), either alone, with SNAC alone or with oral semaglutide. Lack of drug–drug interaction was concluded if 90% confidence intervals (CIs) for the ratio of area under the plasma concentration–time curve (AUC) or maximum concentration (C_max), with/without oral semaglutide, were within a pre-specified interval (0.80–1.25).

Results

The AUC values of ethinylestradiol and levonorgestrel were not affected by oral semaglutide co-administration (estimated ratios [90% CI] 1.06 [1.01–1.10] and 1.06 [0.97–1.17], respectively); C_max was not affected. The no-effect criterion was not met for furosemide or rosuvastatin for the AUC (1.28 [1.16–1.42] and 1.41 [1.24–1.60], respectively) or C_max. SNAC alone did not affect the AUC or C_max of ethinylestradiol, levonorgestrel or rosuvastatin; the C_max of furosemide was slightly decreased. Adverse events were similar to those previously observed for GLP-1RAs (both trials).

Conclusion

Co-administration with oral semaglutide did not affect the pharmacokinetics of ethinylestradiol or levonorgestrel. There was a small increase in exposure of furosemide and rosuvastatin; however, these increases are not expected to be of clinical relevance.

Clinical Trial Registration Numbers

NCT02845219 and NCT03010475.

Supplementary Information

The online version contains supplementary material available at (10.1007/s40262-020-00976-x).

Discovery of nano-piperolactam A: A nonsteroidal contraceptive lead acting through down-regulation of interleukins

Elevated serum interleukins (IL-6, IL-1β) over baseline concentration help in blastocyst adhesion to the uterine endometrium in the early phase of pregnancy. A nano PLA (Piperolactam A)-HPBCD (2-hydroxy-propyl-β-cyclodextrin) inclusion complex was developed as an interleukin down-regulator that exhibited 100% anti-implantation activity in rodents at a dose as low as 2.5-5.0 mg/kg. On metabolomics study, among major glyco-lipo-protein metabolites, only serum low-density lipoprotein (LDL) or very low-density lipoprotein (VLDL) levels revealed alteration by the formulation. Administration of PLA-HPBCD did not cause changes in serum estrogen and progesterone levels. However, IL-6 and IL-1β failed to increase post PLA-HPBCD administration; hence, it is assumed to be the mode of the drug's abortifacient action. In addition, absence of signs of either acute or chronic toxicity suggests the formulation was considerably non-toxic. Therefore, the nano-PLA conjugate promises as a non-steroidal contraceptive lead apart from ormeloxifene, the only non-steroidal anti-fertility agent currently available globally.

Effect of oestrogen/gestagen replacement therapy on liver enzymes in patients with Ullrich-Turner syndrome

The absence of breast development and the prevention of osteoporosis in Ullrich-Turner syndrome (UTS) require oestrogen/gestagen substitution therapy. In 8 out of 35 (23%) patients with UTS treated with conjugated equine oestrogens and cyclically with norethisterone acetate, the serum liver enzymes increased to conspicuous levels (AST 35; 20-73 U/l, ALT 92; 37-141 U/l, GGT 77; 25-227 U/l, [median; min-max]). These findings were compared with those in 41 tall girls who received a six-fold larger dose of conjugated equine oestrogens for the reduction of final height. None of these 41 girls showed abnormal serum liver enzyme levels. The conspicuous rise in serum liver enzyme levels occurred in the majority of the UTS patients before norethistherone acetate was added to the oestrogen replacement therapy. No essential morphological equivalent was found in liver sonography and biopsy studies. During the follow up the elevated serum liver enzyme levels showed reversibility when medication was temporarily discontinued and either a slow decrease or a steady state after therapy was continued. CONCLUSION. Patients with UTS on oral oestrogen replacement therapy are more susceptible to develop increased serum liver enzyme levels as compared with eukaryotic females treated with the same oestrogen preparation for other disorders. As the underlying pathomechanism is unknown and adverse long-term effects cannot be ruled out, avoiding the portal vein and using the transdermal application of oestrogen may represent a viable solution to the problem.

Effect of oral hormone replacement therapy on liver function tests

Five oral methods of hormone replacement therapy (HRT) were prescribed to groups of healthy post-menopausal women and their effects on a group of liver function tests were examined. No evidence of deterioration in liver function was noted.

Effect of oral contraceptive on liver function tests of women with schistosomiasis in the Philippines

A prospective study was undertaken to determine the effect on liver function tests of a combined oral contraceptive containing norethisterone 1 mg and mestranol 0.05 mg, in women with schistosomiasis japonica in Leyte, Philippines. Women who volunteered and met the standard criteria for oral contraception, with and without infection, were followed for six months of pill intake. Concurrently, non-pill users, both infected and uninfected, were similarly followed. Baseline and six-month liver function tests were compared. Of the 466 subjects admitted in the study, 383 completed six months, and 83 discontinued. At the start of the study, there were no significant differences among the four groups in liver function tests except that the infected women had a higher total protein and alkaline phosphatase, and lower alanine aminotransferase levels. After six months, the only statistically significant finding was a lesser decrease in total protein among the infected pill users compared to the uninfected pill users. This finding was not clinically significant since there was no associated clinical complications; there were fewer number of subjects with abnormal values at the sixth month; and the mean values of this variable remained within normal limits. Our findings show that the use of low dose progestin and estrogen oral contraceptive in the presence of mild schistosomiasis japonica infection does not appear to have adverse effect on liver function tests of young women after six months of contraceptive use.

Effects of oral contraception on liver function tests and serum proteins in women with past viral hepatitis

Forty-three women who had viral hepatitis one or more years ago and 35 healthy women who were age and parity matched were given an oral contraceptive containing 0.05mg ethinyl estradiol and 0.5mg levonorgestrel for six consecutive months. Liver function tests (serum bilirubin, SGOT, SGPT and serum alkaline phosphatase) and serum proteins (total, albumin, globulins, ceruloplasmin, haptoglobin and alpha-1 antitrypsin) were measured before beginning treatment and after three and six months of use. Past hepatitis women experienced increased unconjugated bilirubin, SGOT, SGPT and alkaline phosphatase levels throughout the six months while the control women showed less pronounced changes during the first three months with tendency to reversion to normal during the subsequent three months; the group X time of test interactions were significantly different between the two groups. Serum haptoglobin decreased significantly in both groups but the past-hepatitis group showed a more persistent change with time. Changes also occurred in serum albumin, alpha-1 and beta globulins, ceruloplasmin but without group effect or group X time interactions.