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Geng K, Shen C, Wang X, Wang X, Shao W, Wang W, Chen T, Sun H, Xie H. A physiologically-based pharmacokinetic/pharmacodynamic modeling approach for drug-drug-gene interaction evaluation of S-warfarin with fluconazole. CPT Pharmacometrics Syst Pharmacol 2024; 13:853-869. [PMID: 38487942 PMCID: PMC11098157 DOI: 10.1002/psp4.13123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/17/2024] [Accepted: 02/07/2024] [Indexed: 05/18/2024] Open
Abstract
Warfarin is a widely used anticoagulant, and its S-enantiomer has higher potency compared to the R-enantiomer. S-warfarin is mainly metabolized by cytochrome P450 (CYP) 2C9, and its pharmacological target is vitamin K epoxide reductase complex subunit 1 (VKORC1). Both CYP2C9 and VKORC1 have genetic polymorphisms, leading to large variations in the pharmacokinetics (PKs) and pharmacodynamics (PDs) of warfarin in the population. This makes dosage management of warfarin difficult, especially in the case of drug-drug interactions (DDIs). This study provides a whole-body physiologically-based pharmacokinetic/PD (PBPK/PD) model of S-warfarin for predicting the effects of drug-drug-gene interactions on S-warfarin PKs and PDs. The PBPK/PD model of S-warfarin was developed in PK-Sim and MoBi. Drug-dependent parameters were obtained from the literature or optimized. Of the 34 S-warfarin plasma concentration-time profiles used, 96% predicted plasma concentrations within twofold range compared to observed data. For S-warfarin plasma concentration-time profiles with CYP2C9 genotype, 364 of 386 predicted plasma concentration values (~94%) fell within the twofold of the observed values. This model was tested in DDI predictions with fluconazole as CYP2C9 perpetrators, with all predicted DDI area under the plasma concentration-time curve to the last measurable timepoint (AUClast) ratio within twofold of the observed values. The anticoagulant effect of S-warfarin was described using an indirect response model, with all predicted international normalized ratio (INR) within twofold of the observed values. This model also incorporates a dose-adjustment method that can be used for dose adjustment and predict INR when warfarin is used in combination with CYP2C9 perpetrators.
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Affiliation(s)
- Kuo Geng
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
- Wannan Medical CollegeWuhuAnhuiChina
| | - Chaozhuang Shen
- Department of Clinical Pharmacy and Pharmacy Administration, West China College of PharmacySichuan UniversityChengduSichuanChina
| | - Xiaohu Wang
- Department of PharmaceuticsChina Pharmaceutical UniversityNanjingChina
| | - Xingwen Wang
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
- Wannan Medical CollegeWuhuAnhuiChina
| | - Wenxin Shao
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
- Wannan Medical CollegeWuhuAnhuiChina
| | - Wenhui Wang
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
- Wannan Medical CollegeWuhuAnhuiChina
| | - Tao Chen
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
- Wannan Medical CollegeWuhuAnhuiChina
| | - Hua Sun
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
| | - Haitang Xie
- Anhui Provincial Center for Drug Clinical EvaluationYijishan Hospital of Wannan Medical CollegeWuhuAnhuiChina
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Pouncey DL, Barnette DA, Sinnott RW, Phillips SJ, Flynn NR, Hendrickson HP, Swamidass SJ, Miller GP. Discovery of Novel Reductive Elimination Pathway for 10-Hydroxywarfarin. Front Pharmacol 2022; 12:805133. [PMID: 35095511 PMCID: PMC8793337 DOI: 10.3389/fphar.2021.805133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/20/2021] [Indexed: 11/20/2022] Open
Abstract
Coumadin (R/S-warfarin) anticoagulant therapy is highly efficacious in preventing the formation of blood clots; however, significant inter-individual variations in response risks over or under dosing resulting in adverse bleeding events or ineffective therapy, respectively. Levels of pharmacologically active forms of the drug and metabolites depend on a diversity of metabolic pathways. Cytochromes P450 play a major role in oxidizing R- and S-warfarin to 6-, 7-, 8-, 10-, and 4′-hydroxywarfarin, and warfarin alcohols form through a minor metabolic pathway involving reduction at the C11 position. We hypothesized that due to structural similarities with warfarin, hydroxywarfarins undergo reduction, possibly impacting their pharmacological activity and elimination. We modeled reduction reactions and carried out experimental steady-state reactions with human liver cytosol for conversion of rac-6-, 7-, 8-, 4′-hydroxywarfarin and 10-hydroxywarfarin isomers to the corresponding alcohols. The modeling correctly predicted the more efficient reduction of 10-hydroxywarfarin over warfarin but not the order of the remaining hydroxywarfarins. Experimental studies did not indicate any clear trends in the reduction for rac-hydroxywarfarins or 10-hydroxywarfarin into alcohol 1 and 2. The collective findings indicated the location of the hydroxyl group significantly impacted reduction selectivity among the hydroxywarfarins, as well as the specificity for the resulting metabolites. Based on studies with R- and S-7-hydroxywarfarin, we predicted that all hydroxywarfarin reductions are enantioselective toward R substrates and enantiospecific for S alcohol metabolites. CBR1 and to a lesser extent AKR1C3 reductases are responsible for those reactions. Due to the inefficiency of reactions, only reduction of 10-hydroxywarfarin is likely to be important in clearance of the metabolite. This pathway for 10-hydroxywarfarin may have clinical relevance as well given its anticoagulant activity and capacity to inhibit S-warfarin metabolism.
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Affiliation(s)
- Dakota L Pouncey
- Department of Biochemistry and Molecular Biology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Dustyn A Barnette
- Department of Biochemistry and Molecular Biology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Riley W Sinnott
- Department of Biochemistry and Molecular Biology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Sarah J Phillips
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Noah R Flynn
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, United States
| | - Howard P Hendrickson
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, United States.,Department of Pharmaceutical Social and Administrative Sciences, McWhorter School of Pharmacy, Samford University, Birmingham, AL, United States
| | - S Joshua Swamidass
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, United States
| | - Grover P Miller
- Department of Biochemistry and Molecular Biology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States
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Industrial Approach to Determine the Relative Contribution of Seven Major UGT Isoforms to Hepatic Glucuronidation. J Pharm Sci 2020; 109:2309-2320. [DOI: 10.1016/j.xphs.2020.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 02/28/2020] [Accepted: 03/23/2020] [Indexed: 01/19/2023]
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Alshogran OY. Warfarin Dosing and Outcomes in Chronic Kidney Disease: A Closer Look at Warfarin Disposition. Curr Drug Metab 2019; 20:633-645. [PMID: 31267868 DOI: 10.2174/1389200220666190701095807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/02/2019] [Accepted: 06/12/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Chronic Kidney Disease (CKD) is a prevalent worldwide health problem. Patients with CKD are more prone to developing cardiovascular complications such as atrial fibrillation and stroke. This warrants the use of oral anticoagulants, such as warfarin, in this population. While the efficacy and safety of warfarin in this setting remain controversial, a growing body of evidence emphasizes that warfarin use in CKD can be problematic. This review discusses 1) warfarin use, dosing and outcomes in CKD patients; and 2) possible pharmacokinetic mechanisms for altered warfarin dosing and response in CKD. METHODS Structured search and review of literature articles evaluating warfarin dosing and outcomes in CKD. Data and information about warfarin metabolism, transport, and pharmacokinetics in CKD were also analyzed and summarized. RESULTS The literature data suggest that changes in warfarin pharmacokinetics such as protein binding, nonrenal clearance, the disposition of warfarin metabolites may partially contribute to altered warfarin dosing and response in CKD. CONCLUSION Although the evidence to support warfarin use in advanced CKD is still unclear, this synthesis of previous findings may help in improving optimized warfarin therapy in CKD settings.
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Affiliation(s)
- Osama Y Alshogran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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