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Xia H, Xu X, Chen J, Wu H, Shen Y, Chen X, Xu RA, Wu W. Inhibitory effects of calcium channel blockers nisoldipine and nimodipine on ivacaftor metabolism and their underlying mechanism. Front Pharmacol 2024; 15:1403649. [PMID: 39329117 PMCID: PMC11424460 DOI: 10.3389/fphar.2024.1403649] [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: 03/19/2024] [Accepted: 09/04/2024] [Indexed: 09/28/2024] Open
Abstract
Ivacaftor is the first potentiator of the cystic fibrosis transmembrane conductance regulator (CFTR) protein approved for use alone in the treatment of cystic fibrosis (CF). Ivacaftor is primarily metabolized by CYP3A4 and therefore may interact with drugs that are CYP3A4 substrates, resulting in changes in plasma exposure to ivacaftor. The study determined the levels of ivacaftor and its active metabolite M1 by ultra performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS). We screened 79 drugs and 19 severely inhibited ivacaftor metabolism, particularly two cardiovascular drugs (nisoldipine and nimodipine). In rat liver microsomes (RLM) and human liver microsomes (HLM), the half-maximal inhibitory concentrations (IC50) of nisoldipine on ivacaftor metabolism were 6.55 μM and 9.10 μM, respectively, and the inhibitory mechanism of nisoldipine on ivacaftor metabolism was mixed inhibition; the IC50 of nimodipine on ivacaftor metabolism in RLM and HLM were 4.57 μM and 7.15 μM, respectively, and the inhibitory mechanism of nimodipine on ivacaftor was competitive inhibition. In pharmacokinetic experiments in rats, it was observed that both nisoldipine and nimodipine significantly altered the pharmacokinetic parameters of ivacaftor, such as AUC(0-t) and CLz/F. However, this difference may not be clinically relevant. In conclusion, this paper presented the results of studies investigating the interaction between these drugs and ivacaftor in vitro and in vivo. The objective is to provide a rationale for the safety of ivacaftor in combination with other drugs.
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Affiliation(s)
| | | | | | | | | | | | - Ren-ai Xu
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wenzhi Wu
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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2
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Pietri T, Laugier D, Rouby F, Micallef J. Pharmacokinetic drug-drug interactions between Paxlovid® (nirmatrelvir/ritonavir) and CFTR modulators for cystic fibrosis. Therapie 2024; 79:475-476. [PMID: 37730449 DOI: 10.1016/j.therap.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 08/04/2023] [Accepted: 09/08/2023] [Indexed: 09/22/2023]
Affiliation(s)
- Tessa Pietri
- Service de pharmacologie clinique et de pharmacovigilance, AMU Inserm 1106, AP-HM, CRPV Marseille Provence-Corse, 270, boulevard de Sainte-Marguerite, 13385 Marseille, France.
| | - Delphine Laugier
- Service de pharmacologie clinique et de pharmacovigilance, AMU Inserm 1106, AP-HM, CRPV Marseille Provence-Corse, 270, boulevard de Sainte-Marguerite, 13385 Marseille, France
| | - Frank Rouby
- Service de pharmacologie clinique et de pharmacovigilance, AMU Inserm 1106, AP-HM, CRPV Marseille Provence-Corse, 270, boulevard de Sainte-Marguerite, 13385 Marseille, France
| | - Joëlle Micallef
- Service de pharmacologie clinique et de pharmacovigilance, AMU Inserm 1106, AP-HM, CRPV Marseille Provence-Corse, 270, boulevard de Sainte-Marguerite, 13385 Marseille, France
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3
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Hong E, Zampoli M, Beringer PM. Pharmacokinetic Enhancement of Elexacaftor/Tezacaftor/Ivacaftor for Cystic Fibrosis: A Cost Reduction Strategy to Address Global Disparities in Access. Clin Pharmacol Ther 2024; 115:1204-1207. [PMID: 38385853 DOI: 10.1002/cpt.3214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/01/2024] [Indexed: 02/23/2024]
Affiliation(s)
- Eunjin Hong
- College of Pharmacy, CHA University, Seongnam-si, South Korea
| | - Marco Zampoli
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Paul M Beringer
- Department of Clinical Pharmacy, Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, California, USA
- USC Anton Yelchin CF Clinic, Los Angeles, California, USA
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Hassan SS, Shams R, Camps I, Basharat Z, Sohail S, Khan Y, Ullah A, Irfan M, Ali J, Bilal M, Morel CM. Subtractive sequence analysis aided druggable targets mining in Burkholderia cepacia complex and finding inhibitors through bioinformatics approach. Mol Divers 2023; 27:2823-2847. [PMID: 36567421 PMCID: PMC9790820 DOI: 10.1007/s11030-022-10584-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/05/2022] [Indexed: 12/27/2022]
Abstract
Burkholderia cepacia complex (BCC) is a group of gram-negative bacteria composed of at least 20 different species that cause diseases in plants, animals as well as humans (cystic fibrosis and airway infection). Here, we analyzed the proteomic data of 47 BCC strains by classifying them in three groups. Phylogenetic analyses were performed followed by individual core region identification for each group. Comparative analysis of the three individual core protein fractions resulted in 1766 ortholog/proteins. Non-human homologous proteins from the core region gave 1680 proteins. Essential protein analyses reduced the target list to 37 proteins, which were further compared to a closely related out-group, Burkholderia gladioli ATCC 10,248 strain, resulting in 21 proteins. 3D structure modeling, validation, and druggability step gave six targets that were subjected to further target prioritization parameters which ultimately resulted in two BCC targets. A library of 12,000 ZINC drug-like compounds was screened, where only the top hits were selected for docking orientations. These included ZINC01405842 (against Chorismate synthase aroC) and ZINC06055530 (against Bifunctional N-acetylglucosamine-1-phosphate uridyltransferase/Glucosamine-1-phosphate acetyltransferase glmU). Finally, dynamics simulation (200 ns) was performed for each ligand-receptor complex, followed by ADMET profiling. Of these targets, details of their applicability as drug targets have not yet been elucidated experimentally, hence making our predictions novel and it is suggested that further wet-lab experimentations should be conducted to test the identified BCC targets and ZINC scaffolds to inhibit them.
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Affiliation(s)
- Syed Shah Hassan
- Jamil–ur–Rehman Center for Genome Research, Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, 75270 Pakistan
- Centre for Technological Development in Health (CDTS), Oswaldo Cruz Foundation (Fiocruz), Building “Expansão”, 8th Floor Room 814, Av. Brasil 4036, Manguinhos, Rio de Janeiro, RJ 21040-361 Brazil
- Department of Chemistry, Islamia College Peshawar, Peshawar, 25000 KP Pakistan
| | - Rida Shams
- Department of Chemistry, Islamia College Peshawar, Peshawar, 25000 KP Pakistan
| | - Ihosvany Camps
- Laboratório de Modelagem Computacional—LaModel, Instituto de Ciências Exatas—ICEx. Universidade Federal de Alfenas—UNIFAL-MG, Alfenas, Minas Gerais Brazil
- High Performance & Quantum Computing Labs, Waterloo, Canada
| | - Zarrin Basharat
- Jamil–ur–Rehman Center for Genome Research, Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, 75270 Pakistan
| | - Saman Sohail
- Department of Chemistry, Islamia College Peshawar, Peshawar, 25000 KP Pakistan
| | - Yasmin Khan
- Jamil–ur–Rehman Center for Genome Research, Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, 75270 Pakistan
| | - Asad Ullah
- Department of Chemistry, Islamia College Peshawar, Peshawar, 25000 KP Pakistan
| | - Muhammad Irfan
- Jamil–ur–Rehman Center for Genome Research, Dr. Panjwani Center for Molecular Medicine and Drug Research, International Center for Chemical and Biological Sciences, University of Karachi, Karachi, 75270 Pakistan
| | - Javed Ali
- Department of Chemistry, Kohat University of Science & Technology–KUST, Kohat, KP Pakistan
| | - Muhammad Bilal
- Department of Chemistry, Kohat University of Science & Technology–KUST, Kohat, KP Pakistan
| | - Carlos M. Morel
- Centre for Technological Development in Health (CDTS), Oswaldo Cruz Foundation (Fiocruz), Building “Expansão”, 8th Floor Room 814, Av. Brasil 4036, Manguinhos, Rio de Janeiro, RJ 21040-361 Brazil
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VanElzakker MB, Tillman EM, Yonker LM, Ratai EM, Georgiopoulos AM. Neuropsychiatric adverse effects from CFTR modulators deserve a serious research effort. Curr Opin Pulm Med 2023; 29:603-609. [PMID: 37655981 PMCID: PMC10552811 DOI: 10.1097/mcp.0000000000001014] [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] [Indexed: 09/02/2023]
Abstract
PURPOSE OF REVIEW This review highlights the problem of neuropsychiatric adverse effects (AEs) associated with elexacaftor/tezacaftor/ivacaftor (ETI), current suboptimal mitigation approaches, a novel testable mechanistic hypothesis, and potential solutions requiring further research. RECENT FINDINGS Studies show that a minority of persons with cystic fibrosis (PwCF) initiating cystic fibrosis transmembrane conductance regulator (CFTR) modulators experience neuropsychiatric AEs including worsening mood, cognition, anxiety, sleep, and suicidality. The GABA-A receptor is a ligand-gated chloride channel, and magnetic resonance spectroscopy neuroimaging studies have shown that reduced GABA expression in rostral anterior cingulate cortex is associated with anxiety and depression. Recent research details the impact of peripheral inflammation and the gut-brain axis on central neuroinflammation. Plasma ETI concentrations and sweat chloride have been evaluated in small studies of neuropsychiatric AEs but not validated to guide dose titration or correlated with pharmacogenomic variants or safety/efficacy. SUMMARY Although ETI is well tolerated by most PwCF, some experience debilitating neuropsychiatric AEs. In some cases, these AEs may be driven by modulation of CFTR and chloride transport within the brain. Understanding biological mechanisms is a critical next step in identifying which PwCF are likely to experience AEs, and in developing evidence-based strategies to mitigate them, while retaining modulator efficacy.
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Bergagnini-Kolev MC, Hsu S, Aitken ML, Goss CH, Hoofnagle AN, Zelnick LR, Lum D, Best CM, Thummel KE, Kestenbaum BR, de Boer IH, Lin YS. Metabolism and pharmacokinetics of vitamin D in patients with cystic fibrosis. J Steroid Biochem Mol Biol 2023; 232:106332. [PMID: 37217104 PMCID: PMC10524963 DOI: 10.1016/j.jsbmb.2023.106332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/15/2023] [Accepted: 05/19/2023] [Indexed: 05/24/2023]
Abstract
Patients with cystic fibrosis (CF) commonly have lower circulating concentrations of 25-hydroxyvitamin D (25(OH)D) than healthy populations. We comprehensively compared measures of vitamin D metabolism among individuals with CF and healthy control subjects. In a cross-sectional study, serum from participants with CF (N = 83) and frequency-matched healthy control subjects by age and race (N = 82) were analyzed for: 25(OH)D2 and 25(OH)D3, 1α,25-dihydroxyvitamins D2 and D3 (1α,25(OH)2D2 and 1α,25(OH)2D3), 24,25-dihydroxyvitamin D3 (24,25(OH)2D3), 4β,25-dihydroxyvitamin D3 (4β,25(OH)2D3), 25-hydroxyvitamin D3-3-sulfate (25(OH)D3-S), and 25-hydroxyvitamin D3-3-glucuronide (25(OH)D3-G). In a 56-day prospective pharmacokinetic study, ∼25 μg deuterium-labeled 25(OH)D3 (d6-25(OH)D3) was administered intravenously to participants (N = 5 with CF, N = 5 control subjects). Serum was analyzed for d6-25(OH)D3 and d6-24,25(OH)2D3, and pharmacokinetic parameters were estimated. In the cross-sectional study, participants with CF had similar mean (SD) total 25(OH)D concentrations as control subjects (26.7 [12.3] vs. 27.7 [9.9] ng/mL) and had higher vitamin D supplement use (53% vs. 22%). However, participants with CF had lower total 1α,25(OH)2D (43.6 [12.7] vs. 50.7 [13.0] pg/mL), 4β,25(OH)2D3 (52.1 [38.9] vs. 79.9 [60.2] pg/mL), and 25(OH)D3-S (17.7 [11.6] vs. 30.1 [12.3] ng/mL) (p < 0.001 for all). The pharmacokinetics of d6-25(OH)D3 and d6-24,25(OH)D3 did not differ between groups. In summary, although 25(OH)D concentrations were comparable, participants with CF had lower 1α,25(OH)2D, 4β,25(OH)2D3, and 25(OH)D3-S concentrations than healthy controls. Neither 25(OH)D3 clearance, nor formation of 24,25(OH)2D3, appears to account for these differences and alternative mechanisms for low 25(OH)D in CF (i.e., decreased formation, altered enterohepatic recirculation) should be explored.
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Affiliation(s)
| | - Simon Hsu
- Kidney Research Institute, University of Washington, Seattle, WA 98104, USA; Division of Nephrology, Department of Medicine, School of Medicine, University of Washington, Seattle, WA 98195, USA.
| | - Moira L Aitken
- Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Christopher H Goss
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA 98195, USA; Department of Medicine, School of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Andrew N Hoofnagle
- Kidney Research Institute, University of Washington, Seattle, WA 98104, USA; Department of Laboratory Medicine and Pathology, School of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Leila R Zelnick
- Kidney Research Institute, University of Washington, Seattle, WA 98104, USA; Division of Nephrology, Department of Medicine, School of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Dawn Lum
- Kidney Research Institute, University of Washington, Seattle, WA 98104, USA; Division of Nephrology, Department of Medicine, School of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Cora M Best
- Kidney Research Institute, University of Washington, Seattle, WA 98104, USA; Department of Laboratory Medicine and Pathology, School of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Kenneth E Thummel
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Bryan R Kestenbaum
- Kidney Research Institute, University of Washington, Seattle, WA 98104, USA; Division of Nephrology, Department of Medicine, School of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Ian H de Boer
- Kidney Research Institute, University of Washington, Seattle, WA 98104, USA; Division of Nephrology, Department of Medicine, School of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Yvonne S Lin
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, WA 98195, USA
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Bentley S, Cheong J, Gudka N, Makhecha S, Hadjisymeou-Andreou S, Standing JF. Therapeutic drug monitoring-guided dosing for pediatric cystic fibrosis patients: recent advances and future outlooks. Expert Rev Clin Pharmacol 2023; 16:715-726. [PMID: 37470695 DOI: 10.1080/17512433.2023.2238597] [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: 03/23/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Medicine use in children with cystic fibrosis (CF) is complicated by inconsistent pharmacokinetics at variance with the general population, a lack of research into this and its effects on clinical outcomes. In the absence of established dose regimens, therapeutic drug monitoring (TDM) is a clinically relevant tool to optimize drug exposure and maximize therapeutic effect by the bedside. In clinical practice though, use of this is variable and limited by a lack of expert recommendations. AREAS COVERED We aimed to review the use of TDM in children with CF to summarize recent developments, current recommendations, and opportunities for future directions. We searched PubMed for relevant publications using the broad search terms "cystic fibrosis" in combination with the specific terms "therapeutic drug monitoring (TDM)" and "children." Further searches were undertaken using the name of identified drugs combined with the term "TDM." EXPERT OPINION Further research into the use of Bayesian forecasting and the relationship between exposure and response is required to personalize dosing, with the opportunity for the development of expert recommendations in children with CF. Use of noninvasive methods of TDM has the potential to improve accessibility to TDM in this cohort.
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Affiliation(s)
- Siân Bentley
- Pharmacy Department, Royal Brompton Hospital, London, UK
| | - Jamie Cheong
- Pharmacy Department, Royal Brompton Hospital, London, UK
| | - Nikesh Gudka
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | - Joseph F Standing
- Pharmacy Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation,great Ormond Street Institute of Child Health, University College London, London, UK
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Purkayastha D, Agtarap K, Wong K, Pereira O, Co J, Pakhale S, Kanji S. Drug-drug interactions with CFTR modulator therapy in cystic fibrosis: Focus on Trikafta®/Kaftrio®. J Cyst Fibros 2023; 22:478-483. [PMID: 36653239 DOI: 10.1016/j.jcf.2023.01.005] [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: 06/30/2022] [Revised: 12/21/2022] [Accepted: 01/11/2023] [Indexed: 01/18/2023]
Abstract
The combination of CFTR modulators ivacaftor, tezacaftor and elexacaftor (Trikafta®, Kaftrio®) significantly improve outcomes, including survival in a broad range of cystic fibrosis patients. These drugs have complicated metabolic profiles that make the potential for drug interactions an important consideration for prescribers, care providers and patients. Prolonged survival also increases risk of age-related disease and their associated pharmacotherapy, further increasing the risk of drug interactions and the need for increased vigilance amongst care providers. We systematically searched the literature for studies identifying and evaluating pharmacokinetic and pharmacodynamic drug interactions involving the components of Trikafta®/Kaftrio®. We also searched electronic databases of drugs for possible drug interactions based on metabolic profiles. We identified 86 potential drug interactions of which 13 were supported by 14 studies. There is a significant need for research to describe the likelihood, magnitude and clinical impact of the drug interactions proposed here.
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Affiliation(s)
| | | | - Kristy Wong
- University of Waterloo, Kitchener, ON, Canada
| | | | - Jannie Co
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Smita Pakhale
- Department of Medicine, The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, Ottawa Hospital Research Institute, 501 Smyth Rd, Ottawa, ON K1H 8L6, Canada.
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Hong E, Shi A, Beringer P. Drug-drug interactions involving CFTR modulators: a review of the evidence and clinical implications. Expert Opin Drug Metab Toxicol 2023; 19:203-216. [PMID: 37259485 DOI: 10.1080/17425255.2023.2220960] [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: 02/22/2023] [Accepted: 05/30/2023] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Cystic fibrosis (CF) is characterized by mucus accumulation impairing the lungs, gastrointestinal tract, and other organs. Cystic fibrosis transmembrane conductance regulator (CFTR) modulators (ivacaftor, tezacaftor, elexacaftor, and lumacaftor) significantly improve lung function and nutritional status; however, they are substrates, inhibitors, and/or inducers of certain CYP enzymes and transporters, raising the risk of drug-drug interactions (DDI) with common CF medications. AREAS COVERED A literature search was conducted for DDIs involving CFTR modulators by reviewing new drug applications, drug package inserts, clinical studies, and validated databases of substrates, inhibitors, and inducers. Clinically, CYP3A inducers and inhibitors significantly decrease and increase systemic concentrations of elexacaftor/tezacaftor/ivacaftor, respectively. Additionally, lumacaftor and ivacaftor alter concentrations of CYP3A and P-gp substrates. Potential DDIs without current clinical evidence include ivacaftor and elexacaftor's effect on CYP2C9 and OATP1B1/3 substrates, respectively, and OATP1B1/3 and P-gp inhibitors' effect on tezacaftor. A literature review was conducted using PubMed. EXPERT OPINION Dosing recommendations for CFTR modulators with DDIs are relatively comprehensive; however, recommendations on timing of dosing transition of CFTR modulators when CYP3A inhibitors are initiated or discontinued is incomplete. Certain drug interactions may be managed by choosing an alternative treatment to avoid/minimize DDIs. Next generation CFTR modulator therapies under development are expected to provide increased activity with reduced DDI risk.
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Affiliation(s)
- Eunjin Hong
- Department of Clinical Pharmacy, USC Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, USA
| | - Alan Shi
- Department of Clinical Pharmacy, USC Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, USA
| | - Paul Beringer
- Department of Clinical Pharmacy, USC Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, USA
- USC Anton Yelchin CF Clinic, Los Angeles, CA, USA
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The influence of exocrine pancreatic function on the exposure and pharmacokinetics of ivacaftor in people with cystic fibrosis. J Cyst Fibros 2022:S1569-1993(22)01420-5. [DOI: 10.1016/j.jcf.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/14/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
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Guimbellot JS, Ryan KJ, Anderson JD, Parker KL, Odom LV, Rowe SM, Acosta EP. Plasma and cellular ivacaftor concentrations in patients with cystic fibrosis. Pediatr Pulmonol 2022; 57:2745-2753. [PMID: 35927224 PMCID: PMC9588676 DOI: 10.1002/ppul.26093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/29/2022] [Accepted: 07/25/2022] [Indexed: 11/08/2022]
Abstract
Access to cystic fibrosis transmembrane conductance regulator (CFTR) modulators has been gradually increasing for people with cystic fibrosis, the first of which was ivacaftor, a CFTR potentiator that is part of all clinically available modulator treatments. In this study, we hypothesized that the steady-state concentrations in blood and tissue are highly variable in patients taking ivacaftor in a real-world context, which may have an impact on the treatment approach. We collected nasal epithelial cells to estimate target site concentrations and blood samples to estimate pharmacokinetic parameters at a steady state. We found that patients on ivacaftor monotherapy have variable concentrations well above the maximal effective concentration and may maintain concentrations necessary for the clinical benefit even if dosing is reduced. We also are the first to provide detailed target site concentration data over time, which shows that tissue concentrations do not fluctuate significantly and do not correlate with plasma concentrations. These findings show that some patients may have higher-than-expected concentrations and may benefit from tailored dosing to balance clinical response with side effects or adherence needs.
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Affiliation(s)
- Jennifer S. Guimbellot
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham (UAB), Birmingham, AL
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, UAB, Birmingham, AL
| | - Kevin J. Ryan
- Department of Pharmacology and Toxicology, Division of Clinical Pharmacology, UAB, Birmingham, AL
| | - Justin D. Anderson
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, UAB, Birmingham, AL
| | - Kennedy L. Parker
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, UAB, Birmingham, AL
| | - L. Victoria Odom
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, UAB, Birmingham, AL
| | - Steven M. Rowe
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham (UAB), Birmingham, AL
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, UAB, Birmingham, AL
- Departments of Medicine and Cell Developmental and Integrative Biology, UAB, Birmingham, AL
| | - Edward P. Acosta
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham (UAB), Birmingham, AL
- Department of Pharmacology and Toxicology, Division of Clinical Pharmacology, UAB, Birmingham, AL
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Physiologically Based Pharmacokinetic Modeling To Guide Management of Drug Interactions between Elexacaftor-Tezacaftor-Ivacaftor and Antibiotics for the Treatment of Nontuberculous Mycobacteria. Antimicrob Agents Chemother 2022; 66:e0110422. [PMID: 36286508 PMCID: PMC9664863 DOI: 10.1128/aac.01104-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Nontuberculous mycobacteria (NTM) are the pathogens of concern in people with cystic fibrosis (pwCF) due to their association with deterioration of lung function. Treatment requires the use of a multidrug combination regimen, creating the potential for drug-drug interactions (DDIs) with cystic fibrosis transmembrane conductance regulator (CFTR)-modulating therapies, including elexacaftor, tezacaftor, and ivacaftor (ETI), which are eliminated mainly through cytochrome P450 (CYP) 3A-mediated metabolism. An assessment of the DDI risk for ETI coadministered with NTM treatments, including rifabutin, clofazimine, and clarithromycin, is needed to provide appropriate guidance on dosing.
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Abstract
Over the past decade there have been significant developments in the field of Cystic Fibrosis Transmembrane Regulator modulator drugs. Following treatment in patients with cystic fibrosis with common gating mutations using the potentiator drug ivacaftor, successive development of corrector drugs used in combination has led to highly effective modulator therapy being available to more than 85% of the cystic fibrosis population over 12 years of age in the form of elexacaftor/tezacaftor/ivacaftor. In this article, we review the evidence from clinical trials and mounting real-world observational and registry data that demonstrates the impact highly effective modulators have on both pulmonary and extra-pulmonary manifestations of cystic fibrosis. As clinical trials progress to younger patient groups, we discuss the challenges to demonstrating drug efficacy in early life, and also consider practicalities of drug development in an ever-shrinking modulator-naïve population. Drug-drug interactions are an important consideration in people with cystic fibrosis, where polypharmacy is commonplace, but also as the modulated population look to remain healthier for longer, we identify trials that aim to address treatment burden too. Inequity of care, through drug cost or ineligibility for modulators by genotype, is widening without apparent strategies to address this; however, we present evidence of hopeful early-stage drug development for non-modulatable genes and summarise the current state of gene-therapy development.
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Sakon CM, Tillman EM. Pharmacogenomics: a tool to improve medication safety and efficacy in patients with cystic fibrosis. Pharmacogenomics 2022; 23:559-556. [PMID: 35670256 DOI: 10.2217/pgs-2022-0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cystic fibrosis is a genetic, multiorgan system disease that involves the use of many medications to control symptoms associated with the underlying condition. Many of these medications have Clinical Pharmacogenetics Implementation Consortium evidence-based guidelines for pharmacogenomics that are available to guide dosing. The aim of this article is to review relevant literature and evaluate the utility of preemptive pharmacogenomics testing for persons with cystic fibrosis and propose a pharmacogenomics panel that could be considered standard of care for persons with cystic fibrosis.
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Affiliation(s)
- Colleen M Sakon
- Pharmacy Department, Indiana University Health, Indianapolis, IN, USA
| | - Emma M Tillman
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, IN, USA
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