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Hou Q, Chen Y, Zhang Y, Pang C. Comparative Muscle Tolerability of Different Types and Intensities of Statins: A Network Meta-Analysis of Double-Blind Randomized Controlled Trials. Cardiovasc Drugs Ther 2024; 38:459-469. [PMID: 36447018 DOI: 10.1007/s10557-022-07405-0] [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] [Accepted: 11/04/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE The benefits of statins for ischemic cardio-cerebrovascular diseases are well known. However, concerns around muscle adverse events still exist. We therefore aimed to compare the muscle safety of individual statins in adults. METHODS PubMed, Embase, Cochrane Central Register of Controlled Trials and Web of Science were searched to include double-blind randomized controlled trials (RCTs) comparing one statin with another or with control treatment. Pairwise meta-analyses and network meta-analyses were undertaken with Stata 14.0 software. Relative risk (RR) with 95% confidence intervals (CIs) was adopted for each outcome. RESULTS A total of 83 RCTs were included. In the pairwise meta-analysis, statins were significantly associated with only a slight increase in muscle symptoms compared with control (RR=1.05; 95% CI=1.01-1.09). In the drug-level network meta-analyses, no statistically significant difference was found between individual statins in the incidence of muscle symptoms, myalgia, myopathy, rhabdomyolysis, creatine kinase (CK) >10 times the upper limit of normal (ULN) or discontinuation due to muscle adverse events. In the dose-level network meta-analyses, there were no statistically significant dose-dependent effects on any outcomes except that moderate-intensity statins had a higher incidence of muscle symptoms than control (RR=1.13; 95% CI=1.01-1.27). Moderate simvastatin (RR=6.57; 95% CI=1.26-34.41) and moderate pravastatin (RR=5.96; 95% CI=1.00-35.44) had a statistically significantly higher incidence of CK >10×ULN compared with moderate atorvastatin. Lipophilic statins and statins metabolized by liver cytochrome P450 3A4 were not associated with an increased risk of muscle adverse events. CONCLUSION Statins may be generally safe on muscle. Moderate atorvastatin may be superior to equivalent simvastatin and pravastatin in muscle tolerability.
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Affiliation(s)
- Qingtao Hou
- Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, 1# Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China.
| | - Yuqin Chen
- Neuroscience Research Center, College of Basic Medicine, Chongqing Medical University, Chongqing, 400016, People's Republic of China
| | - Yingxiao Zhang
- Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, 1# Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Caishuang Pang
- Chongqing Medical University, Chongqing, 400016, People's Republic of China
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Wu BJ, Wu SYS, Chen CH, Hsiao YF, Huang CS, Liu WS. Effect of Genetic Polymorphisms in Detoxification Proteins on Treatment Outcome of Atorvastatin. INT J PHARMACOL 2017. [DOI: 10.3923/ijp.2017.198.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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3
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Rafeeq MM, Ahmad F, Rahman SZ, Siddiqi SS, Shakil S. Effect of an SNP in SCAP gene on lipid-lowering response to rosuvastatin in Indian patients with metabolic syndrome. Pharmacogenomics 2016; 17:2015-2024. [PMID: 27885915 DOI: 10.2217/pgs.16.30] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
AIM Statins treat dyslipidemia associated with metabolic syndrome. Genetic factors contribute to variable response. Sterol regulatory element-binding factors cleavage-activating protein (SCAP) pathway regulates lipid homeostasis, so effect of SNP in SCAP gene on rosuvastatin response was studied. MATERIALS & METHODS Metabolic syndrome patients with low-density lipoprotein-cholesterol ≥130 mg/dl, were prescribed rosuvastatin 5 mg for 3 months. Lipids were measured initially and finally, and genotyping done. RESULTS & CONCLUSION Sixty-three patients completed the study. Twenty-three were homozygous for AA while 40 were heterozygous. Significant association was found between post-treatment lipid values and SCAP genotypes but not with baseline values. Cholesterol (p = 0.002) and low-density lipoprotein-cholesterol (p = 0.008) were significantly reduced in patients carrying G allele as compared with AA. There was a significant effect of G allele on cholesterol reduction (p = 0.043). Out of total responders (achieving >23.58% total cholesterol reduction), 80.5% were 2386G carriers (GG+GA) and only 19.5% were homozygous for A allele (p = 0.0048). SCAP 2386A>G gene polymorphism is a significant predictor of hypolipidemic response.
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Affiliation(s)
- Misbahuddin M Rafeeq
- Department of Pharmacology, Rabigh College of Medicine, King Abdulaziz University, Jeddah, 21589, Saudi Arabia
| | - Farida Ahmad
- Department of Pharmacology, Faculty of Medicine, Aligarh Muslim University, Aligarh, 202002, India
| | - Syed Z Rahman
- Department of Pharmacology, Faculty of Medicine, Aligarh Muslim University, Aligarh, 202002, India
| | - Sheelu S Siddiqi
- Rajiv Gandhi Centre for Diabetes & Endocrinology, Faculty of Medicine, Aligarh Muslim University, Aligarh, 202002, India
| | - Shazi Shakil
- Centre for Innovation in Personalized Medicine, King Abdulaziz University, Jeddah, 21589, Saudi Arabia
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4
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Sahoo S, Haraldsdóttir HS, Fleming RMT, Thiele I. Modeling the effects of commonly used drugs on human metabolism. FEBS J 2014; 282:297-317. [PMID: 25345908 DOI: 10.1111/febs.13128] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 09/21/2014] [Accepted: 10/13/2014] [Indexed: 02/02/2023]
Abstract
Metabolism contributes significantly to the pharmacokinetics and pharmacodynamics of a drug. In addition, diet and genetics have a profound effect on cellular metabolism with respect to both health and disease. In the present study, we assembled a comprehensive, literature-based drug metabolic reconstruction of the 18 most highly prescribed drug groups, including statins, anti-hypertensives, immunosuppressants and analgesics. This reconstruction captures in detail our current understanding of their absorption, intracellular distribution, metabolism and elimination. We combined this drug module with the most comprehensive reconstruction of human metabolism, Recon 2, yielding Recon2_DM1796, which accounts for 2803 metabolites and 8161 reactions. By defining 50 specific drug objectives that captured the overall drug metabolism of these compounds, we investigated the effects of dietary composition and inherited metabolic disorders on drug metabolism and drug-drug interactions. Our main findings include: (a) a shift in dietary patterns significantly affects statins and acetaminophen metabolism; (b) disturbed statin metabolism contributes to the clinical phenotype of mitochondrial energy disorders; and (c) the interaction between statins and cyclosporine can be explained by several common metabolic and transport pathways other than the previously established CYP3A4 connection. This work holds the potential for studying adverse drug reactions and designing patient-specific therapies.
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Affiliation(s)
- Swagatika Sahoo
- Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Belval, Luxembourg
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5
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Shingaki T, Takashima T, Ijuin R, Zhang X, Onoue T, Katayama Y, Okauchi T, Hayashinaka E, Cui Y, Wada Y, Suzuki M, Maeda K, Kusuhara H, Sugiyama Y, Watanabe Y. Evaluation of Oatp and Mrp2 Activities in Hepatobiliary Excretion Using Newly Developed Positron Emission Tomography Tracer [11C]Dehydropravastatin in Rats. J Pharmacol Exp Ther 2013; 347:193-202. [DOI: 10.1124/jpet.113.206425] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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6
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Dunn SP, Holmes DR, Moliterno DJ. Drug-drug interactions in cardiovascular catheterizations and interventions. JACC Cardiovasc Interv 2013; 5:1195-208. [PMID: 23257367 DOI: 10.1016/j.jcin.2012.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 10/09/2012] [Accepted: 10/16/2012] [Indexed: 12/29/2022]
Abstract
Patients presenting for invasive cardiovascular procedures are frequently taking a variety of medications aimed to treat risk factors related to heart and vascular disease. During the procedure, antithrombotic, sedative, and analgesic medications are commonly needed, and after interventional procedures, new medications are often added for primary and secondary prevention of ischemic events. In addition to these prescribed medications, the use of over-the-counter drugs and supplements continues to rise. Most elderly patients, for example, are taking 5 or more prescribed medications and 1 or more supplements, and they often have some degree of renal insufficiency. This polypharmacy might result in drug-drug interactions that affect the balance of thrombotic and bleeding events during the procedure and during long-term treatment. Mixing of anticoagulants, for instance, might lead to periprocedural bleeding, and this is associated with an increase in long-term adverse events. Furthermore, the range of possible interactions with thienopyridine antiplatelets is of concern, because these drugs are essential to immediate and extended interventional success. The practical challenges in the field are great-some drug-drug interactions are likely present yet not well understood due to limited assays, whereas other interactions have well-described biological effects but seem to be more theoretical, because there is little to no clinical impact. Interventional providers need to be attentive to the potential for drug-drug interaction, the associated harm, and the appropriate action, if any, to minimize the potential for medication-related adverse events. This review will focus on drug-drug interactions that have the potential to affect procedural success, either through increases in immediate complications or compromising longer-term outcome.
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Affiliation(s)
- Steven P Dunn
- Department of Pharmacy Services, University of Virginia, Charlottesville, Virginia, USA
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7
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Kroiss M, Quinkler M, Lutz WK, Allolio B, Fassnacht M. Drug interactions with mitotane by induction of CYP3A4 metabolism in the clinical management of adrenocortical carcinoma. Clin Endocrinol (Oxf) 2011; 75:585-91. [PMID: 21883349 DOI: 10.1111/j.1365-2265.2011.04214.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Mitotane [1-(2-chlorophenyl)-1-(4-chlorophenyl)-2,2-dichloroethane, (o,p'-DDD)] is the only drug approved for the treatment for adrenocortical carcinoma (ACC) and has also been used for various forms of glucocorticoid excess. Through still largely unknown mechanisms, mitotane inhibits adrenal steroid synthesis and adrenocortical cell proliferation. Mitotane increases hepatic metabolism of cortisol, and an increased replacement dose of glucocorticoids is standard of care during mitotane treatment. Recently, sunitinib, a multityrosine kinase inhibitor (TKI), has been found to be rapidly metabolized by CYP3A4 during mitotane treatment, indicating clinically relevant drug interactions with mitotane. We here summarize the current evidence concerning mitotane-induced changes in hepatic monooxygenase expression, list drugs potentially affected by mitotane-related CYP3A4 induction and suggest alternatives. For example, using standard doses of macrolide antibiotics is unlikely to reach sufficient plasma levels, making fluoroquinolones in many cases a superior choice. Similarly, statins such as simvastatin are metabolized by CYP3A4, whereas others like pravastatin are not. Importantly, in the past, several clinical trials using cytotoxic drugs but also targeted therapies in ACC yielded disappointing results. This lack of antineoplastic activity may be explained in part by insufficient drug exposure owing to enhanced drug metabolism induced by mitotane. Thus, induction of CYP3A4 by mitotane needs to be considered in the design of future clinical trials in ACC.
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Affiliation(s)
- Matthias Kroiss
- Endocrine and Diabetes Unit, Department of Internal Medicine I, University Hospital Würzburg, and University of Würzburg, Würzburg, Germany.
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Yasar U, Sain-Guven G, Yardimci Y, Kilicarslan A, Babaoglu MO, Bozkurt A. Effect of atorvastatin on CYP2C9 metabolic activity as measured by the formation rate of losartan metabolite in hypercholesterolaemic patients. Basic Clin Pharmacol Toxicol 2011; 109:73-7. [PMID: 21332946 DOI: 10.1111/j.1742-7843.2011.00687.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
HMG-CoA reductase inhibitors (statins) have a potential to interact with substrates of the drug-metabolizing enzyme cytochrome P450 2C9 (CYP2C9). This may lead to concentration-dependent toxicity such as skeletal muscle side effects. Atorvastatin, a widely used statin, is presently inadequately investigated in vivo with regard to effects on CYP2C9 activity in human beings. The aim of this study was to determine the effect of atorvastatin on the activity of CYP2C9 in a group of Turkish hypercholesterolaemic patients. We prospectively investigated the atorvastatin effect on CYP2C9 activity in a sample of Turkish hypercholesterolaemia patients (11 women, 7 men) who commenced atorvastatin (10 mg/day). Losartan was used as a probe drug to determine CYP2C9 metabolic activity. A single 25-mg oral dose of losartan was given to the patients before, on the first day and after the fourth week of the atorvastatin treatment. Urinary concentrations of losartan and its metabolite, E3174, were measured by high-pressure liquid chromatography (HPLC). Urinary losartan/E3174 ratios were used as an index of CYP2C9 activity. As the baseline enzyme activity may influence the extent of drug-drug interactions, the CYP2C9*2 and 2C9*3 alleles were identified by using PCR-RFLP. In the patients with the CYP2C9*1*1 genotype (n = 12), atorvastatin treatment did not cause a significant change in losartan/E3174 ratios (medians; 95% CI) neither after the first day (0.73; 0.34-1.61) nor at the fourth week (0.71; 0.36-1.77) of the treatment as compared with the baseline activity (0.92; 0.57-1.74, p = 0.38). Similarly, no significant change in the baseline CYP2C9 activity (0.91; 0.30-1.60) was observed in patients with the CYP2C9*1*2 genotype as compared with those of the first day (1.08; 0.08-2.72) and fourth week (0.64; 0.0-3.82) of the atorvastatin treatment (n = 4, p = 0.86). These observations in a hypercholesterolaemic patient sample suggest that atorvastatin does not have a significant effect on enzymes encoded by the CYP2C9*1*1 and CYP2C9*1*2 genotypes when co-administered with a CYP2C9 substrate, losartan.
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Affiliation(s)
- Umit Yasar
- Departments of Pharmacology, Hacettepe University, Sihhiye, Ankara, Turkey.
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9
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The Isoprenoid Biosynthetic Pathway and Statins. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/b978-0-12-415922-8.00012-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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11
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Long-term treatment with pitavastatin is effective and well tolerated by patients with primary hypercholesterolemia or combined dyslipidemia. Atherosclerosis 2009; 210:202-8. [PMID: 20080236 DOI: 10.1016/j.atherosclerosis.2009.12.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 11/30/2009] [Accepted: 12/04/2009] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The primary objective was to assess the safety and tolerability of pitavastatin 4mg once daily during 52 weeks treatment. The secondary objectives were to assess the effect on lipid and lipoprotein fractions and ratios, and LDL-C target attainment. METHODS Patients with primary hypercholesterolemia or combined dyslipidemia who had previously received pitavastatin, atorvastatin or simvastatin for 12 weeks during double-blind phase III studies received open-label pitavastatin 4mg once daily for up to 52 weeks. RESULTS Investigators at 72 sites enrolled 1353 patients who received at least one dose of pitavastatin 4mg; 155 (11.5%) patients discontinued treatment during the 52-week follow up. The proportion of patients achieving NCEP and EAS LDL-C targets at week 52 was 74.0% and 73.5% respectively. The reduction in LDL-C levels seen during the double-blind studies was sustained, while HDL-C levels rose continually during follow up, ultimately increasing by 14.3% over the initial baseline. Changes in other efficacy parameters (triglycerides, total cholesterol, non-HDL-C, Apo-A1 and Apo-B, high sensitivity C-reactive protein, oxidised LDL) and ratios (total cholesterol: HDL-C, non-HDL-C:HDL-C and Apo-B:Apo-A1) were sustained during 52-weeks treatment compared with the end of the double-blind studies. Pitavastatin was well tolerated: 4.1% of patients withdrew from the study due to treatment emergent adverse events (TEAEs) and none of the serious adverse events were considered treatment-related. No clinically significant abnormalities were associated with pitavastatin in routine laboratory variables, urinalysis, vital signs or 12-lead ECG. There were no reports of myopathy, myositis or rhabdomyolysis. The most common TEAEs were: increased creatine phosphokinase (5.8%), nasopharyngitis (5.4%) and myalgia (4.1%). CONCLUSION Pitavastatin 4mg once daily was effective and well tolerated during 52-weeks treatment in patients with primary hypercholesterolemia or combined dyslipidemia. Around three-quarters of patients achieved NCEP and EAS LDL-C targets at week 52, HDL-C levels rose continually during follow up, while changes in other efficacy parameters were sustained over the year-long study.
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12
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Bertrand-Thiebault C, Masson C, Siest G, Batt AM, Visvikis-Siest S. Effect of HMGCoA reductase inhibitors on cytochrome P450 expression in endothelial cell line. J Cardiovasc Pharmacol 2007; 49:306-15. [PMID: 17513950 DOI: 10.1097/fjc.0b013e31803e8756] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Endothelial cells and smooth muscle cells are the major cells that constitute blood vessels, and endothelial cells line the lumen of blood vessels. These 2 types of cells also play an integral role in the regional specialization of vascular structure. On the basis of these observations, we designed our study to investigate the effect of various statins on CYP expression in endothelial cells. 3-hydroxymethyl coenzyme A reductase inhibitors play an important role in vascular function. The majority of the statins available on the market show extensive metabolism by cytochrome P450 (CYP) enzymes. Both cell types are involved in the bioconversion of arachidonic acid into vasoactive compounds. The aim of this study was to demonstrate the effect of statins on cytochrome P450 expression in endothelial cells. Our results show that endothelial cells expressed both CYPs involved in epoxyeicosatrienoic acids (EETs) and hydroxyeicosatetraenoic acids (HETEs) production and the nuclear receptor implicated in cytochrome P450 regulation. Treatment of endothelial cells with lovastatin increased CYP2C9 expression. After 96 hours of treatment, fluvastatin and lovastatin clearly increased CYP2C9 protein level. CAR but not PXR was expressed in endothelial cells, indicating that the upregulating effect of statins on CYP2C9 in endothelial cells could be mediated through CAR only due to the lack of expression of PXR in these cells.
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MESH Headings
- Analysis of Variance
- Aryl Hydrocarbon Hydroxylases/drug effects
- Aryl Hydrocarbon Hydroxylases/metabolism
- Atorvastatin
- Blotting, Western
- Cell Line
- Cell Proliferation/drug effects
- Cell Survival/drug effects
- Constitutive Androstane Receptor
- Cytochrome P-450 CYP2C9
- Cytochrome P-450 Enzyme System/biosynthesis
- Cytochrome P-450 Enzyme System/drug effects
- Endothelial Cells/drug effects
- Endothelial Cells/enzymology
- Endothelium, Vascular/cytology
- Fatty Acids, Monounsaturated/pharmacology
- Fluvastatin
- Gene Expression Regulation, Enzymologic/drug effects
- Heptanoic Acids/pharmacology
- Humans
- Hydroxymethylglutaryl-CoA Reductase Inhibitors/pharmacology
- Indoles/pharmacology
- Lovastatin/pharmacology
- Pravastatin/pharmacology
- Pregnane X Receptor
- Pyrroles/pharmacology
- RNA, Messenger/drug effects
- RNA, Messenger/metabolism
- Receptors, Cytoplasmic and Nuclear/biosynthesis
- Receptors, Cytoplasmic and Nuclear/drug effects
- Receptors, Glucocorticoid/biosynthesis
- Receptors, Glucocorticoid/drug effects
- Receptors, Steroid/biosynthesis
- Receptors, Steroid/drug effects
- Reverse Transcriptase Polymerase Chain Reaction
- Saphenous Vein/cytology
- Transcription Factors/biosynthesis
- Transcription Factors/drug effects
- Up-Regulation/drug effects
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Abstract
Considerable effort has been devoted to improving the pharmacologic characteristics and clinical effects of statins. Desirable pharmacologic properties include potent inhibition of hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase, selectivity of uptake in hepatocytes, low systemic bioavailability to reduce systemic adverse effects, prolonged elimination half-life, and no or minimal hepatic metabolism to avoid drug-drug interactions. The desirable effects on lipid variables would include increased effectiveness in reducing levels of low-density lipoprotein cholesterol and other atherogenic lipoproteins and measurable beneficial effects on high-density lipoprotein cholesterol levels. As a product of the ongoing efforts regarding statin pharmacology, the new statin rosuvastatin exhibits significant improvements in several of these characteristics.
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Affiliation(s)
- James M McKenney
- National Clinical Research, Inc., and School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA.
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15
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Krasteva AZ, Mitcheva MK, Kondeva-Burdina MS, Descatoire VA. In vitro study of lovastatin interactions with amiodarone and with carbon tetrachloride in isolated rat hepatocytes. World J Gastroenterol 2007; 13:2198-204. [PMID: 17465501 PMCID: PMC4146844 DOI: 10.3748/wjg.v13.i15.2198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the interactions at a metabolic level between lovastatin, amiodarone and carbon tetrachloride in isolated rat hepatocytes.
METHODS: For cell isolation two-step collagenase liver perfusion was performed. Lovastatin was administered alone in increasing concentrations (1 μmol/L, 3 μmol/L, 5 μmol/L and 10 μmol/L) and in combination with CCl4 (86 μmol/L). The cells were also pretreated with 14 μmol/L amiodarone and then the other two compounds were added.
RESULTS: Lovastatin promoted concentration-dependent significant toxicity estimated by decrease in cell viability and GSH level by 45% and 84%, respectively. LDH-activity increased by 114% and TBARS content by 90%. CCl4 induced the expected severe damage on the examined parameters. CCl4 induced toxicity was attenuated after lovastatin pretreatment, which was expressed in less increased values of LDH activity and TBARS levels, as well as in less decreased cell viability and GSH concentrations. However, the pretreatment of hepatocytes with amiodarone abolished the protective effect of lovastatin.
CONCLUSION: We suggest that the observed cytopro-tective effect was due to interactions between lovastatin, CCl4 and amiodarone at a metabolic level.
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Affiliation(s)
- A-Z Krasteva
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Medical University, 2 Dunav str., Sofia 1000, Bulgaria.
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16
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Sunder‐Plassmann R. Cytochrome P450: Another Player in the Myocardial Infarction Game? Adv Clin Chem 2007. [DOI: 10.1016/s0065-2423(06)43008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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17
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Schmitz G, Langmann T. Pharmacogenomics of cholesterol-lowering therapy. Vascul Pharmacol 2006; 44:75-89. [PMID: 16337220 DOI: 10.1016/j.vph.2005.07.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2005] [Accepted: 07/01/2005] [Indexed: 12/25/2022]
Abstract
The prevention of cardiovascular disease is critically dependent on lipid-lowering therapy, including 3-hydroxymethyl-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins), cholesterol absorption inhibitors, bile acid resins, fibrates, and nicotinic acid. Although these drugs are generally well tolerated, severe adverse effects can occur in a minority of patients. Furthermore, a subset of patients does not respond to cholesterol-lowering therapy with a reduction in coronary heart disease progression. Significant progress has been made in the identification of common DNA sequence variations in genes influencing the pharmacokinetics and pharmacodynamics of statins and in disease-modifying genes relevant for coronary heart disease (CHD). Among the most promising candidate genes for pharmacogenomic analysis of statin therapy are HMG-CoA reductase as a direct target gene and other genes modulating lipid and lipoprotein homeostasis. Based on data from pharmacogenetic trials, a combined analysis of multiple genetic variants in several genes is more likely to give significant results than single gene studies in small cohorts. In the future, pharmacogenomic testing may allow risk stratification of patients to avoid serious side effects and enable clinicians to select lipid-lowering drugs with the highest efficacy resulting in the best response to therapy.
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Affiliation(s)
- Gerd Schmitz
- Institute of Clinical Chemistry and Laboratory Medicine, University of Regensburg, Franz-Josef-Straub-Allee 11, 93042 Regensburg, Germany.
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Alayli G, Cengiz K, Cantürk F, Durmuş D, Akyol Y, Menekşe EB. Acute Myopathy in a Patient with Concomitant Use of Pravastatin and Colchicine. Ann Pharmacother 2005; 39:1358-61. [PMID: 15914514 DOI: 10.1345/aph.1e593] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report a case of acute myopathy after concomitant use of colchicine and pravastatin. CASE SUMMARY A 65-year-old woman was admitted to the hospital with an acute episode of gout. She had been taking pravastatin 20 mg once daily for 6 years. On admission, blood urea nitrogen and serum creatinine levels were 48 mg/dL and 1.3 mg/dL, respectively. Colchicine 1.5 mg/day was added to the treatment regimen, but 20 days after the initiation of colchicine therapy, symmetrical proximal muscle weakness developed in the woman's legs. Physical examination, laboratory findings, and electromyelogram findings suggested myopathy. The Naranjo probability scale indicated a probable relationship between myopathy and combined therapy. Seven days after discontinuation of colchicine and pravastatin, the patient's weakness improved and enzyme levels returned to normal. Colchicine was restarted at 1.0 mg/day 5 days later; no myopathy occurred. DISCUSSION Hydroxymethylglutaryl coenzyme A reductase inhibitors (statins) and colchicine are known to cause myopathy. Most of the statins and colchicine are biotransformed in the liver primarily by the CYP3A4 system, which may increase the risk of myopathy when concurrent therapy is used. However, pravastatin is not primarily metabolized by cytochrome P450 isoenzymes. The cause of myopathy in our patient may be related to the interaction of colchicine and pravastatin via P-glycoprotein. In addition, the presence of mild renal dysfunction could have contributed to the development of myopathy. CONCLUSIONS We suggest that clinicians be aware that neuromuscular toxicity can occur in patients with mild renal dysfunction with combined use of colchicine and pravastatin.
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Affiliation(s)
- Gamze Alayli
- Department of Physical Medicine and Rehabilitation, Medical Faculty, Ondokuz Mayis University, Samsun, Turkey.
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Straka RJ, Taheri R, Cooper SL, Smith JC. Achieving Cholesterol Target in a Managed Care Organization (ACTION) Trial. Pharmacotherapy 2005; 25:360-71. [PMID: 15843283 DOI: 10.1592/phco.25.3.360.61601] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES To objectively compare the results of a collaborative approach using pharmacists with the results of usual care for achieving a low-density lipoprotein cholesterol (LDL) goal of 100 mg/dl or less in outpatients with documented coronary heart disease (CHD) who are not at goal, and to document the effect on LDL after removal of such a collaborative model from the study population. DESIGN Prospective, multiclinic, controlled study. SETTING Four clinics of a 19-clinic staff model health maintenance organization in Minneapolis and St. Paul, Minnesota. Two clinics treated the intervention patients, two the controls; one clinic for each group was suburban, and one for each was urban. PATIENTS Four hundred eighty-one patients aged 18 years or older with CHD and whose LDL levels were not at goal. INTERVENTION Clinical pharmacists implemented the physician-approved care plan for each intervention patient; activities included managing lipid-lowering drug therapy and educating patients on cardiovascular risk reduction. MEASUREMENTS AND MAIN RESULTS Primary outcomes were changes in LDL level and the proportion of patients achieving goal LDL in the intervention versus the usual care (control) group. Secondary outcomes were the sustainability of the impact observed up to 18 months after discontinuation of the intervention. Mean+/-SD baseline LDL levels were 131+/-28 and 131+/-26 mg/dl (p=NS) for the intervention and control groups, respectively. After a mean of 6.5 months follow-up, 107 (72%) patients in the intervention group and 61 (18%) patients in the control group had attained their LDL goal (p<0.001). Mean LDL levels were reduced by 35.6 mg/dl (27.5%) and 6.7 mg/dl (4.6%) in the intervention and control groups, respectively (p<0.001). When the active program was discontinued, results of the 18-month follow-up indicated that 85 (65%) intervention patients remained at goal compared with 96 (42%) controls (p<0.001). CONCLUSION This trial provides quantitative evidence to support the effectiveness of the collaborative approach as an intervention to optimize management of patients with CHD whose LDL levels are not at goal; this approach is specifically called for in the executive summary of the National Cholesterol Education Program Adult Treatment Panel III. Furthermore, this study documents both the magnitude and sustainability of the impact collaborative care models can have in managed care environments.
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Affiliation(s)
- Robert J Straka
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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20
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Andrus MR. Oral anticoagulant drug interactions with statins: case report of fluvastatin and review of the literature. Pharmacotherapy 2004; 24:285-90. [PMID: 14998226 DOI: 10.1592/phco.24.2.285.33137] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 67-year-old man receiving a stable maintenance dosage of warfarin experienced an increased international normalized ratio (INR) without bleeding when his atorvastatin therapy was switched to fluvastatin. His warfarin dosage was reduced and his INR stabilized. The fluvastatin was switched back to atorvastatin, and the warfarin dosage was increased to maintain the patient's goal INR. The literature supports a drug interaction between warfarin and fluvastatin due to the strong affinity of fluvastatin for the cytochrome P450 enzyme 2D6. This interaction has not been seen with atorvastatin. Lovastatin also reportedly has caused increases in INR when coadministered with warfarin. It is unclear whether simvastatin interacts with warfarin, but it may increase INRs slightly or increase serum simvastatin levels. One case report describes an interaction between simvastatin and the anticoagulant acenocoumarol, which resulted in an elevated INR. Pravastatin does not appear to interact with warfarin but has caused an increased INR when combined with the anticoagulant fluindione. Thus, until more definitive data are available, clinicians should monitor the INR closely after starting statin therapy in any patient receiving anticoagulation therapy.
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Affiliation(s)
- Miranda R Andrus
- Harrison School of Pharmacy, Auburn University, Auburn, Alabama, USA
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21
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Abstract
Hypercholesterolaemia is a risk factor for the development of atherosclerotic disease. Atorvastatin lowers plasma low-density lipoprotein (LDL) cholesterol levels by inhibition of HMG-CoA reductase. The mean dose-response relationship has been shown to be log-linear for atorvastatin, but plasma concentrations of atorvastatin acid and its metabolites do not correlate with LDL-cholesterol reduction at a given dose. The clinical dosage range for atorvastatin is 10-80 mg/day, and it is given in the acid form. Atorvastatin acid is highly soluble and permeable, and the drug is completely absorbed after oral administration. However, atorvastatin acid is subject to extensive first-pass metabolism in the gut wall as well as in the liver, as oral bioavailability is 14%. The volume of distribution of atorvastatin acid is 381L, and plasma protein binding exceeds 98%. Atorvastatin acid is extensively metabolised in both the gut and liver by oxidation, lactonisation and glucuronidation, and the metabolites are eliminated by biliary secretion and direct secretion from blood to the intestine. In vitro, atorvastatin acid is a substrate for P-glycoprotein, organic anion-transporting polypeptide (OATP) C and H+-monocarboxylic acid cotransporter. The total plasma clearance of atorvastatin acid is 625 mL/min and the half-life is about 7 hours. The renal route is of minor importance (<1%) for the elimination of atorvastatin acid. In vivo, cytochrome P450 (CYP) 3A4 is responsible for the formation of two active metabolites from the acid and the lactone forms of atorvastatin. Atorvastatin acid and its metabolites undergo glucuronidation mediated by uridinediphosphoglucuronyltransferases 1A1 and 1A3. Atorvastatin can be given either in the morning or in the evening. Food decreases the absorption rate of atorvastatin acid after oral administration, as indicated by decreased peak concentration and increased time to peak concentration. Women appear to have a slightly lower plasma exposure to atorvastatin for a given dose. Atorvastatin is subject to metabolism by CYP3A4 and cellular membrane transport by OATP C and P-glycoprotein, and drug-drug interactions with potent inhibitors of these systems, such as itraconazole, nelfinavir, ritonavir, cyclosporin, fibrates, erythromycin and grapefruit juice, have been demonstrated. An interaction with gemfibrozil seems to be mediated by inhibition of glucuronidation. A few case studies have reported rhabdomyolysis when the pharmacokinetics of atorvastatin have been affected by interacting drugs. Atorvastatin increases the bioavailability of digoxin, most probably by inhibition of P-glycoprotein, but does not affect the pharmacokinetics of ritonavir, nelfinavir or terfenadine.
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Affiliation(s)
- Hans Lennernäs
- Department of Pharmacy, Uppsala University, Uppsala, Sweden.
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22
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Keenan JM. Treatment of patients with lipid disorders in the primary care setting: new treatment guidelines and their implications. South Med J 2003; 96:266-75. [PMID: 12659359 DOI: 10.1097/01.smj.0000061513.59902.6a] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Coronary heart disease (CHD) remains a major cause of morbidity and mortality throughout North America. The role played by lipid abnormalities is now well established, and primary care physicians can play a major role in reversing the increasing prevalence of CHD by following the recommended guidelines of the National Cholesterol Expert Panel (NCEP ATP-III). While many physicians are aware of the importance of lowering lipid levels, a large number of patients still fail to reach their treatment goals. It is therefore important to identify patients at risk of developing coronary events due to abnormal lipid profiles and to quickly implement effective prevention programs. Although diet and other lifestyle modifications should form the basis of lipid management, the addition of lipid-modifying drugs is often necessary. Several lipid-modifying agents are available, but the proven efficacy and good tolerability of statins has increasingly made them the drugs of choice.
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Affiliation(s)
- Joseph M Keenan
- Department of Family Practice and Community Health, School of Medicine, University of Minnesota, Minneapolis, MN 55455-0392, USA.
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Farnier M, Bortolini M, Salko T, Freudenreich MO, Isaacsohn JL, Troendle AJ, Gonasun L. Frequency of creatine kinase elevation during treatment with fluvastatin in combination with fibrates (bezafibrate, fenofibrate, or gemfibrozil). Am J Cardiol 2003; 91:238-40. [PMID: 12521642 DOI: 10.1016/s0002-9149(02)03116-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Each of the lipid-lowering agents available today can cause myopathy. The severity of the muscle disorder may vary from trivial myalgias or elevations of creatine kinase in asymptomatic individuals to rhabdomyolysis with myoglobinuria, renal failure, and death. Fortunately, significant myopathy occurs at a low rate. However, the large number of individuals taking these medications renders it a significant problem. Although the pathophysiology of the myopathy remains speculative, its occurrence appears to be dose related. Consequently, the total dosage of lipid-lowering drug consumed, the concomitant use of other medications that affect their blood levels, and the individual's specific drug-metabolizing enzyme profile may contribute to this toxicity.
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Affiliation(s)
- Robert L Wortmann
- Department of Internal Medicine, The University of Oklahoma College of Medicine, Tulsa, 74135-2512, USA.
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Hsu WC, Chen WH, Chang MT, Chiu HC. Colchicine-induced acute myopathy in a patient with concomitant use of simvastatin. Clin Neuropharmacol 2002; 25:266-8. [PMID: 12410059 DOI: 10.1097/00002826-200209000-00008] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Colchicine and 3-hydroxy-3-methy-glutaryl coenzyme A (HMG-CoA) reductase inhibitors are well known to cause myopathy. Myotoxicity is dose-dependent in both drugs; therefore, the onset of symptoms usually takes months or years. We report the case of a patient with chronic renal failure who had been taking simvastatin for 2 years and developed acute weakness 2 weeks after the start of treatment with colchicines for recurrent gout. The electromyography and elevated muscle enzymes indicated that his symptoms were caused by myopathy. When this patient stopped taking both drugs, his weakness resolved rapidly. Acute myopathy induced by combination therapy with colchicines and simvastatin is rare. In patients with chronic renal failure, co-administration of colchicine with simvastatin may accelerate the onset of myopathy because CYP3A4 (part of cytochrome P450) is crucial in the breakdown of both drugs. When adding colchicine to a medication regimen that includes a HMG-CoA reductase inhibitor for patients with renal insufficiency, drugs that are metabolized outside the CYP3A4 system (e.g., fluvastatin and pravastatin) should be selected instead.
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Affiliation(s)
- Wei-Chih Hsu
- Department of Neurology, Shin-Kong WHS Memorial Hospital, Taipei, Taiwan.
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26
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Matsuyama K, Nakagawa K, Nakai A, Konishi Y, Nishikata M, Tanaka H, Uchida T. Evaluation of myopathy risk for HMG-CoA reductase inhibitors by urethane infusion method. Biol Pharm Bull 2002; 25:346-50. [PMID: 11913531 DOI: 10.1248/bpb.25.346] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Purpose of the present study was to evaluate the myopathy risk using a urethane infusion method following oral administration of five kinds of commercial HMG-CoA (3-hydroxy-3-methylglutaryl-coenzyme A) reductase inhibitors (HCRIs), (pravastatin (PV), simvastatin (SV), cerivastatin (CeV), atorvastatin (AV), and fluvastatin (FV)) alone or with coadministration of bezafibrate (BF). The solubility of HCRIs in various solvents was determined as a criterion of the physicochemical property. The plasma creatine phosphokinase (CPK) level as a marker of myopathy in normal rats was screened under urethane infusion after oral administration of HCRI alone or with BF coadministration. Also, renal tissue specimens were prepared and the myoglobin remaining in the tissue was visualized by the labeled avidin-biotin technique. The plasma CPK level in normal rats under urethane infusion following oral administration of five kinds of HCRI increased as the dose of HCRI increased, and coadministration of BF further increased the CPK level for each drug. The risk of myopathy evaluated from the CPK level was ranked as follows: CeV>FV>AV>SV>PV. Myoglobin deposition was observed in the cast of proximal tubules, cytoplasm of distal tubules and collecting ducts of rat kidney extracted from rats treated with HCRIs under urethane infusion. Histopathological findings showed that the extent of myoglobin deposition increased on coadministration of BF with each drug. The correlation was found for myopathy risk evaluated by CPK level using the urethane infusion method and drug lipophilicity, ie., the water/n-octanol partition coefficient except for the case of SV. Histopathological findings for the kidney following HCRI treatment also reflected the CPK level in rats under urethane infusion.
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Affiliation(s)
- Kenji Matsuyama
- School of Pharmaceutical Sciences, Mukogawa Women's University, Nishinomiya, Japan.
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Furst BA, Champion KM, Pierre JM, Wirshing DA, Wirshing WC. Possible association of QTc interval prolongation with co-administration of quetiapine and lovastatin. Biol Psychiatry 2002; 51:264-5. [PMID: 11839370 DOI: 10.1016/s0006-3223(01)01333-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND QTc interval prolongation can occur as a result of treatment with both conventional and novel antipsychotic medications and is of clinical concern because of its association with the potentially fatal ventricular arrhythmia, torsade de pointes. METHODS One case is described in which a patient with schizophrenia, who was being treated for dyslipidemia, developed a prolonged QTc interval while taking quetiapine and lovastatin. RESULTS QTc returned to baseline when the lovastatin dose was reduced. CONCLUSIONS QTc prolongation associated with antipsychotic medication occurs in a dose-dependent manner. We therefore hypothesize that the addition of lovastatin caused an increase in plasma quetiapine levels through competitive inhibition of the cytochrome P(450) (CYP) isoenzyme 3A4. Our case highlights the potential for a drug interaction between quetiapine and lovastatin leading to QTc prolongation during the management of dysipidemia in patients with schizophrenia.
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Affiliation(s)
- Benjamin A Furst
- Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles School of Medicine, Los Angeles, California, USA
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28
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Swart EL, van der Hoven B, Groeneveld ABJ, Touw DJ, Danhof M. Correlation between midazolam and lignocaine pharmacokinetics and MEGX formation in healthy volunteers. Br J Clin Pharmacol 2002; 53:133-9. [PMID: 11851636 PMCID: PMC1874292 DOI: 10.1046/j.0306-5251.2001.01182.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AIMS The objectives of the present investigation were: (a) to determine the correlation between lignocaine and midazolam pharmacokinetics following intravenous administration in healthy volunteers, (b) to determine the effects of treatment with an inhibitor of CYP3A4 (erythromycin) on this correlation and (c) to assess the precision of the MEGX-test as a sole predictor of lignocaine and midazolam pharmacokinetics. METHODS The study was conducted in four male and four female healthy volunteers, aged between 21 and 26 years, who received 1 mg kg-1 lignocaine HCl i.v. on days 1, 3, 5, 9 and 10 of the investigation. On days 5 and 10 they also received midazolam, 0.075 mg kg-1 i.v. and from days 6-10 they took erythromycin 500 mg orally, four times daily. Following administration of lignocaine and midazolam, frequent venous blood samples were obtained for determination of the concentrations of lignocaine, MEGX and midazolam. RESULTS In the absence of erythromycin a statistically significant linear correlation was observed between the clearance of lignocaine and midazolam (CL(midazolam)= 0.41 x CL(lignocaine)+ 1.2; r(2) = 0.857; P < 0.001). Erythromycin cotreatment resulted in a loss of the correlation between the two clearances (r(2) = 0.39; P = 0.1). Erythromycin caused a statistically significant reduction in midazolam clearance from the original value of 3.8 to 2.5 (95% CI for the difference -2.27, -0.35) ml kg-1 min-1. Interestingly there was no significant change in the clearance of lignocaine (6.4 vs 5.8 (95% CI for the difference -2.74, -1.51) ml kg-1 min-1). Furthermore no correlation at all was observed between the MEGX-test and lignocaine or midazolam clearances. Considering the data on day 1, 3 and 5 the intra-individual coefficient of variation in the MEGX-test was 45.3% at 15 min and 23.5% at 30 min, respectively. CONCLUSIONS It is concluded that there is a significant correlation between lignocaine and midazolam clearances but this correlation is lost after CYP3A4 inhibition by erythromycin. The MEGX-test is of no value in assessing intra- and inter-individual variability in midazolam clearance.
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Affiliation(s)
- Eleonora L Swart
- Department of Pharmacy and Medical Intensive Care Unit, University Hospital Vrije Universiteit, PO Box 7057, 1007 MB Amsterdam, the Netherlands.
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29
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Abstract
An elevated low-density lipoprotein (LDL) cholesterol level is a strong predictor of coronary heart disease (CHD) risk. Over the past seven years, equally strong evidence has accumulated that lowering LDL cholesterol with HMG-CoA reductase inhibitors or statins reduces CHD risk and there is now widespread use of these agents for the primary and secondary prevention of CHD. Treatment issues remain regarding the appropriate degree of LDL cholesterol reduction and whether, in people with very high levels, it would be preferable to achieve the LDL cholesterol goal with a powerful statin alone or combined with an agent that lowers LDL cholesterol by a different mechanism. The main focus in the development of novel agents is the patient with low high-density lipoprotein (HDL) cholesterol, usually associated with hypertriglyceridaemia. Already prevalent as a risk factor for CHD, this abnormality has been linked with insulin resistance, which is likely to increase greatly over the next decade, along with increasing obesity and diabetes. Agents that have potent HDL cholesterol raising capacity include cholesteryl ester transfer protein (CETP) inhibitors, retinoid X receptor (RXR) selective agonists, specific peroxisome proliferator-activated receptor (PPAR) agonists and oestrogen-like compounds. Another area of development involves agents that will lower both cholesterol and triglyceride levels, such as partial inhibitors of microsomal triglyceride transfer protein (MTP) and perhaps squalene synthase inhibitors and agonists of AMP kinase. Future emphasis will be on correcting all lipid abnormalities for the prevention of CHD, not just lowering LDL cholesterol.
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Affiliation(s)
- J D Best
- University of Melbourne, Department of Medicine, St Vincent's Hospital Melbourne, Victoria 3065, Australia.
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30
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Jacobson TA. Combination lipid-altering therapy: an emerging treatment paradigm for the 21st century. Curr Atheroscler Rep 2001; 3:373-82. [PMID: 11487448 DOI: 10.1007/s11883-001-0075-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
For the care of an expanding segment of the US population with multiple coronary risk factors, combination lipid-altering therapy is emerging as a treatment imperative. The most recent National Cholesterol Education Program's consensus guidelines emphasize long-term global coronary heart disease (CHD) risk status, designate patients with CHD risk equivalents (eg, diabetes, peripheral arterial disease, 20% or more 10-year absolute CHD risk) for aggressive lipid-altering therapy, and deem the metabolic syndrome (eg, obesity, insulin resistance, hypertension, elevated triglycerides, low levels of high-density lipoprotein cholesterol, small dense low-density lipoprotein particles) as a secondary target for intervention. With the advancing age of the US population and the high prevalence of diabetes, the metabolic syndrome, and CHD, increasing numbers of patients will require a more balanced metabolic attack attainable only through combination lipid-altering regimens. Many of these patients, as well as persons at heightened risk for cardiovascular disease because of a range of heritable conditions (eg, familial hypercholesterolemia, familial combined hyperlipidemia), will undoubtedly require binary or ternary regimens involving statins in concert with niacin, fibric-acid derivatives, or bile acid resins. Such approaches enable the clinician to exploit the complementary effects of these agents, allowing them to be administered at low, optimally tolerable doses that are consistent with superior efficacy and a lower risk of adverse events as compared with escalating doses of monotherapy.
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Affiliation(s)
- T A Jacobson
- Department of Medicine, Emory University School of Medicine, Thomas K. Glenn Memorial Bldg., 69 Butler St. S.E., Atlanta, GA 30303, USA.
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