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Jackson KD, Achour B, Lee J, Geffert RM, Beers JL, Latham BD. Novel Approaches to Characterize Individual Drug Metabolism and Advance Precision Medicine. Drug Metab Dispos 2023; 51:1238-1253. [PMID: 37419681 PMCID: PMC10506699 DOI: 10.1124/dmd.122.001066] [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: 08/14/2022] [Revised: 05/30/2023] [Accepted: 06/05/2023] [Indexed: 07/09/2023] Open
Abstract
Interindividual variability in drug metabolism can significantly affect drug concentrations in the body and subsequent drug response. Understanding an individual's drug metabolism capacity is important for predicting drug exposure and developing precision medicine strategies. The goal of precision medicine is to individualize drug treatment for patients to maximize efficacy and minimize drug toxicity. While advances in pharmacogenomics have improved our understanding of how genetic variations in drug-metabolizing enzymes (DMEs) affect drug response, nongenetic factors are also known to influence drug metabolism phenotypes. This minireview discusses approaches beyond pharmacogenetic testing to phenotype DMEs-particularly the cytochrome P450 enzymes-in clinical settings. Several phenotyping approaches have been proposed: traditional approaches include phenotyping with exogenous probe substrates and the use of endogenous biomarkers; newer approaches include evaluating circulating noncoding RNAs and liquid biopsy-derived markers relevant to DME expression and function. The goals of this minireview are to 1) provide a high-level overview of traditional and novel approaches to phenotype individual drug metabolism capacity, 2) describe how these approaches are being applied or can be applied to pharmacokinetic studies, and 3) discuss perspectives on future opportunities to advance precision medicine in diverse populations. SIGNIFICANCE STATEMENT: This minireview provides an overview of recent advances in approaches to characterize individual drug metabolism phenotypes in clinical settings. It highlights the integration of existing pharmacokinetic biomarkers with novel approaches; also discussed are current challenges and existing knowledge gaps. The article concludes with perspectives on the future deployment of a liquid biopsy-informed physiologically based pharmacokinetic strategy for patient characterization and precision dosing.
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Affiliation(s)
- Klarissa D Jackson
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.D.J., J.L., R.M.G., J.L.B., B.D.L.); and Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island (B.A.)
| | - Brahim Achour
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.D.J., J.L., R.M.G., J.L.B., B.D.L.); and Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island (B.A.)
| | - Jonghwa Lee
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.D.J., J.L., R.M.G., J.L.B., B.D.L.); and Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island (B.A.)
| | - Raeanne M Geffert
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.D.J., J.L., R.M.G., J.L.B., B.D.L.); and Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island (B.A.)
| | - Jessica L Beers
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.D.J., J.L., R.M.G., J.L.B., B.D.L.); and Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island (B.A.)
| | - Bethany D Latham
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (K.D.J., J.L., R.M.G., J.L.B., B.D.L.); and Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island (B.A.)
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Henkel L, Jehn U, Thölking G, Reuter S. Tacrolimus-why pharmacokinetics matter in the clinic. FRONTIERS IN TRANSPLANTATION 2023; 2:1160752. [PMID: 38993881 PMCID: PMC11235362 DOI: 10.3389/frtra.2023.1160752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/07/2023] [Indexed: 07/13/2024]
Abstract
The calcineurin inhibitor (CNI) Tacrolimus (Tac) is the most prescribed immunosuppressant drug after solid organ transplantation. After renal transplantation (RTx) approximately 95% of recipients are discharged with a Tac-based immunosuppressive regime. Despite the high immunosuppressive efficacy, its adverse effects, narrow therapeutic window and high intra- and interpatient variability (IPV) in pharmacokinetics require therapeutic drug monitoring (TDM), which makes treatment with Tac a major challenge for physicians. The C/D ratio (full blood trough level normalized by daily dose) is able to classify patients receiving Tac into two major metabolism groups, which were significantly associated with the clinical outcomes of patients after renal or liver transplantation. Therefore, the C/D ratio is a simple but effective tool to identify patients at risk of an unfavorable outcome. This review highlights the challenges of Tac-based immunosuppressive therapy faced by transplant physicians in their daily routine, the underlying causes and pharmacokinetics (including genetics, interactions, and differences between available Tac formulations), and the latest data on potential solutions to optimize treatment of high-risk patients.
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Affiliation(s)
- Lino Henkel
- Department of Medicine D, University of Münster, Münster, Germany
| | - Ulrich Jehn
- Department of Medicine D, University of Münster, Münster, Germany
| | - Gerold Thölking
- Department of Medicine D, University of Münster, Münster, Germany
- Department of Internal Medicine and Nephrology, University Hospital of Münster Marienhospital Steinfurt, Steinfurt, Germany
| | - Stefan Reuter
- Department of Medicine D, University of Münster, Münster, Germany
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Kvitne KE, Åsberg A, Johnson LK, Wegler C, Hertel JK, Artursson P, Karlsson C, Andersson S, Sandbu R, Skovlund E, Christensen H, Jansson‐Löfmark R, Hjelmesæth J, Robertsen I. Impact of type 2 diabetes on in vivo activities and protein expressions of cytochrome P450 in patients with obesity. Clin Transl Sci 2022; 15:2685-2696. [PMID: 36037309 PMCID: PMC9652437 DOI: 10.1111/cts.13394] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 01/26/2023] Open
Abstract
Previous studies have not accounted for the close link between type 2 diabetes mellitus (T2DM) and obesity when investigating the impact of T2DM on cytochrome P450 (CYP) activities. The aim was to investigate the effect of T2DM on in vivo activities and protein expressions of CYP2C19, CYP3A, CYP1A2, and CYP2C9 in patients with obesity. A total of 99 patients from the COCKTAIL study (NCT02386917) were included in this cross-sectional analysis; 29 with T2DM and obesity (T2DM-obesity), 53 with obesity without T2DM (obesity), and 17 controls without T2DM and obesity (controls). CYP activities were assessed after the administration of a cocktail of probe drugs including omeprazole (CYP2C19), midazolam (CYP3A), caffeine (CYP1A2), and losartan (CYP2C9). Jejunal and liver biopsies were also obtained to determine protein concentrations of the respective CYPs. CYP2C19 activity and jejunal CYP2C19 concentration were 63% (-0.39 [95% CI: -0.82, -0.09]) and 40% (-0.09 fmol/μg protein [95% CI: -0.18, -0.003]) lower in T2DM-obesity compared with the obesity group, respectively. By contrast, there were no differences in the in vivo activities and protein concentrations of CYP3A, CYP1A2, and CYP2C9. Multivariable regression analyses also indicated that T2DM was associated with interindividual variability in CYP2C19 activity, but not CYP3A, CYP1A2, and CYP2C9 activities. The findings indicate that T2DM has a significant downregulating impact on CYP2C19 activity, but not on CYP3A, CYP1A2, and CYP2C9 activities and protein concentrations in patients with obesity. Hence, the effect of T2DM seems to be isoform-specific.
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Affiliation(s)
- Kine Eide Kvitne
- Section for Pharmacology and Pharmaceutical Biosciences, Department of PharmacyUniversity of OsloOsloNorway
| | - Anders Åsberg
- Section for Pharmacology and Pharmaceutical Biosciences, Department of PharmacyUniversity of OsloOsloNorway,Department of Transplantation MedicineOslo University HospitalOsloNorway
| | - Line K. Johnson
- The Morbid Obesity CenterVestfold Hospital TrustTønsbergNorway
| | - Christine Wegler
- Department of PharmacyUppsala UniversityUppsalaSweden,DMPK, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM)BioPharmaceuticals R&D, AstraZenecaGothenburgSweden
| | - Jens K. Hertel
- The Morbid Obesity CenterVestfold Hospital TrustTønsbergNorway
| | - Per Artursson
- Department of Pharmacy and Science for Life LaboratoryUppsala UniversityUppsalaSweden
| | - Cecilia Karlsson
- Late‐stage Development, Cardiovascular, Renal and Metabolism (CVRM)BioPharmaceuticals R&D, AstraZenecaGothenburgSweden,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Shalini Andersson
- Oligonucleotide DiscoveryDiscovery Sciences, R&D, AstraZenecaGothenburgSweden
| | - Rune Sandbu
- The Morbid Obesity CenterVestfold Hospital TrustTønsbergNorway,Department of SurgeryVestfold Hospital TrustTønsbergNorway
| | - Eva Skovlund
- Department of Public Health and NursingNorwegian University of Science and Technology, NTNUTrondheimNorway
| | - Hege Christensen
- Section for Pharmacology and Pharmaceutical Biosciences, Department of PharmacyUniversity of OsloOsloNorway
| | - Rasmus Jansson‐Löfmark
- DMPK, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM)BioPharmaceuticals R&D, AstraZenecaGothenburgSweden
| | - Jøran Hjelmesæth
- The Morbid Obesity CenterVestfold Hospital TrustTønsbergNorway,Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical MedicineUniversity of OsloOsloNorway
| | - Ida Robertsen
- Section for Pharmacology and Pharmaceutical Biosciences, Department of PharmacyUniversity of OsloOsloNorway
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Eide Kvitne K, Hole K, Krogstad V, Wollmann BM, Wegler C, Johnson LK, Hertel JK, Artursson P, Karlsson C, Andersson S, Andersson TB, Sandbu R, Hjelmesæth J, Skovlund E, Christensen H, Jansson-Löfmark R, Åsberg A, Molden E, Robertsen I. Correlations between 4β-hydroxycholesterol and hepatic and intestinal CYP3A4: protein expression, microsomal ex vivo activity, and in vivo activity in patients with a wide body weight range. Eur J Clin Pharmacol 2022; 78:1289-1299. [PMID: 35648149 PMCID: PMC9283167 DOI: 10.1007/s00228-022-03336-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/14/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE Variability in cytochrome P450 3A4 (CYP3A4) metabolism is mainly caused by non-genetic factors, hence providing a need for accurate phenotype biomarkers. Although 4β-hydroxycholesterol (4βOHC) is a promising endogenous CYP3A4 biomarker, additional investigations are required to evaluate its ability to predict CYP3A4 activity. This study investigated the correlations between 4βOHC concentrations and hepatic and intestinal CYP3A4 protein expression and ex vivo microsomal activity in paired liver and jejunum samples, as well as in vivo CYP3A4 phenotyping (midazolam) in patients with a wide body weight range. METHODS The patients (n = 96; 78 with obesity and 18 normal or overweight individuals) were included from the COCKTAIL-study (NCT02386917). Plasma samples for analysis of 4βOHC and midazolam concentrations, and liver (n = 56) and jejunal (n = 38) biopsies were obtained. The biopsies for determination of CYP3A4 protein concentration and microsomal activity were obtained during gastric bypass or cholecystectomy. In vivo CYP3A4 phenotyping was performed using semi-simultaneous oral (1.5 mg) and intravenous (1.0 mg) midazolam. RESULTS 4βOHC concentrations were positively correlated with hepatic microsomal CYP3A4 activity (ρ = 0.53, p < 0.001), and hepatic CYP3A4 concentrations (ρ = 0.30, p = 0.027), but not with intestinal CYP3A4 concentrations (ρ = 0.18, p = 0.28) or intestinal microsomal CYP3A4 activity (ρ = 0.15, p = 0.53). 4βOHC concentrations correlated weakly with midazolam absolute bioavailability (ρ = - 0.23, p = 0.027) and apparent oral clearance (ρ = 0.28, p = 0.008), but not with systemic clearance (ρ = - 0.03, p = 0.81). CONCLUSION These findings suggest that 4βOHC concentrations reflect hepatic, but not intestinal, CYP3A4 activity. Further studies should investigate the potential value of 4βOHC as an endogenous biomarker for individual dose requirements of intravenously administered CYP3A4 substrate drugs. TRIAL REGISTRATION Clinical. TRIALS gov identifier: NCT02386917.
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Affiliation(s)
- Kine Eide Kvitne
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Blindern, P.O. Box 1068, 0316, Oslo, Norway.
| | - Kristine Hole
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway.,Department of Life Sciences and Health, Oslo Metropolitan University, Oslo, Norway
| | - Veronica Krogstad
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Blindern, P.O. Box 1068, 0316, Oslo, Norway
| | | | - Christine Wegler
- Department of Pharmacy, Uppsala University, Uppsala, Sweden.,DMPK, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), AstraZeneca, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - Line K Johnson
- The Morbid Obesity Center, Vestfold Hospital Trust, Tønsberg, Norway
| | - Jens K Hertel
- The Morbid Obesity Center, Vestfold Hospital Trust, Tønsberg, Norway
| | - Per Artursson
- Department of Pharmacy and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Cecilia Karlsson
- Clinical Metabolism, Cardiovascular, Renal and Metabolism (CVRM), Late-Stage Development, AstraZeneca, BioPharmaceuticals R&D, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Shalini Andersson
- Oligonucleotide Discovery, Discovery Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Tommy B Andersson
- DMPK, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), AstraZeneca, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - Rune Sandbu
- The Morbid Obesity Center, Vestfold Hospital Trust, Tønsberg, Norway.,Deparment of Surgery, Vestfold Hospital Trust, Tønsberg, Norway
| | - Jøran Hjelmesæth
- The Morbid Obesity Center, Vestfold Hospital Trust, Tønsberg, Norway.,Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eva Skovlund
- Department of Public Health and Nursing, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
| | - Hege Christensen
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Blindern, P.O. Box 1068, 0316, Oslo, Norway
| | - Rasmus Jansson-Löfmark
- DMPK, Research and Early Development, Cardiovascular, Renal and Metabolism (CVRM), AstraZeneca, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - Anders Åsberg
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Blindern, P.O. Box 1068, 0316, Oslo, Norway.,Department of Transplant Medicine, Oslo University Hospital, Oslo, Norway
| | - Espen Molden
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Blindern, P.O. Box 1068, 0316, Oslo, Norway.,Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Ida Robertsen
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Blindern, P.O. Box 1068, 0316, Oslo, Norway
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5
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Kvitne KE, Robertsen I, Skovlund E, Christensen H, Krogstad V, Wegler C, Angeles PC, Wollmann BM, Hole K, Johnson LK, Sandbu R, Artursson P, Karlsson C, Andersson S, Andersson TB, Hjelmesaeth J, Jansson-Löfmark R, Åsberg A. Short- and long-term effects of body weight loss following calorie restriction and gastric bypass on CYP3A-activity - a non-randomized three-armed controlled trial. Clin Transl Sci 2021; 15:221-233. [PMID: 34435745 PMCID: PMC8742654 DOI: 10.1111/cts.13142] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/17/2020] [Accepted: 07/26/2020] [Indexed: 11/29/2022] Open
Abstract
It remains uncertain whether pharmacokinetic changes following Roux-en-Y gastric bypass (RYGB) can be attributed to surgery-induced gastrointestinal alterations per se and/or the subsequent weight loss. The aim was to compare short- and long-term effects of RYGB and calorie restriction on CYP3A-activity, and cross-sectionally compare CYP3A-activity with normal weight to overweight controls using midazolam as probe drug. This three-armed controlled trial included patients with severe obesity preparing for RYGB (n = 41) or diet-induced (n = 41) weight-loss, and controls (n = 18). Both weight-loss groups underwent a 3-week low-energy-diet (<1200 kcal/day) followed by a 6-week very-low-energy-diet or RYGB (both <800 kcal/day). Patients were followed for 2 years, with four pharmacokinetic investigations using semisimultaneous oral and intravenous dosing to determine changes in midazolam absolute bioavailability and clearance, within and between groups. The RYGB and diet groups showed similar weight-loss at week 9 (13 ± 2.4% vs. 11 ± 3.6%), but differed substantially after 2 years (-30 ± 7.0% vs. -3.1 ± 6.3%). At baseline, mean absolute bioavailability and clearance of midazolam were similar in the RYGB and diet groups, but higher compared with controls. On average, absolute bioavailability was unaltered at week 9, but decreased by 40 ± 7.5% in the RYGB group and 32 ± 6.1% in the diet group at year 2 compared with baseline, with no between-group difference. No difference in clearance was observed over time, nor between groups. In conclusion, neither RYGB per se nor weight loss impacted absolute bioavailability or clearance of midazolam short term. Long term, absolute bioavailability was similarly decreased in both groups despite different weight loss, suggesting that the recovered CYP3A-activity is not only dependent on weight-loss through RYGB.
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Affiliation(s)
- Kine Eide Kvitne
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Ida Robertsen
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Eva Skovlund
- Department of Public Health and Nursing, Norwegian University of Science and Technology, NTNU, Trondheim, Norway
| | - Hege Christensen
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Veronica Krogstad
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Christine Wegler
- Department of Pharmacy, Uppsala University, Uppsala, Sweden.,DMPK, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Mölndal, Sweden
| | - Philip Carlo Angeles
- Vestfold Hospital Trust, The Morbid Obesity Center, Tønsberg, Norway.,Department of Surgery, Vestfold Hospital Trust, Tønsberg, Norway
| | | | - Kristine Hole
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | | | - Rune Sandbu
- Vestfold Hospital Trust, The Morbid Obesity Center, Tønsberg, Norway.,Department of Surgery, Vestfold Hospital Trust, Tønsberg, Norway
| | - Per Artursson
- Department of Pharmacy and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Cecilia Karlsson
- Late-stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Mölndal, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Shalini Andersson
- Research and Early Development, Discovery Sciences, BioPharmaceuticals R&D, AstraZeneca, Mölndal, Sweden
| | - Tommy B Andersson
- DMPK, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Mölndal, Sweden
| | - Jøran Hjelmesaeth
- Vestfold Hospital Trust, The Morbid Obesity Center, Tønsberg, Norway.,Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rasmus Jansson-Löfmark
- DMPK, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Mölndal, Sweden
| | - Anders Åsberg
- Section for Pharmacology and Pharmaceutical Biosciences, Department of Pharmacy, University of Oslo, Oslo, Norway.,Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
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Zwart TC, Guchelaar HJ, van der Boog PJM, Swen JJ, van Gelder T, de Fijter JW, Moes DJAR. Model-informed precision dosing to optimise immunosuppressive therapy in renal transplantation. Drug Discov Today 2021; 26:2527-2546. [PMID: 34119665 DOI: 10.1016/j.drudis.2021.06.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/21/2021] [Accepted: 06/04/2021] [Indexed: 12/18/2022]
Abstract
Immunosuppressive therapy is pivotal for sustained allograft and patient survival after renal transplantation. However, optimally balanced immunosuppressive therapy is challenged by between-patient and within-patient pharmacokinetic (PK) variability. This could warrant the application of personalised dosing strategies to optimise individual patient outcomes. Pharmacometrics, the science that investigates the xenobiotic-biotic interplay using computer-aided mathematical modelling, provides options to describe and quantify this PK variability and enables identification of patient characteristics affecting immunosuppressant PK and treatment outcomes. Here, we review and critically appraise the available pharmacometric model-informed dosing solutions for the typical immunosuppressants in modern renal transplantation, to guide their initial and subsequent dosing.
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Affiliation(s)
- Tom C Zwart
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands; Leiden Network for Personalised Therapeutics, Leiden, the Netherlands
| | - Paul J M van der Boog
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands; LUMC Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Jesse J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands; Leiden Network for Personalised Therapeutics, Leiden, the Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Johan W de Fijter
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands; LUMC Transplant Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Dirk Jan A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands; Leiden Network for Personalised Therapeutics, Leiden, the Netherlands.
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7
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Song IH, Ilic K, Murphy J, Lasseter K, Martin P. Effects of Maribavir on P-Glycoprotein and CYP2D6 in Healthy Volunteers. J Clin Pharmacol 2020; 60:96-106. [PMID: 31385617 PMCID: PMC6972521 DOI: 10.1002/jcph.1504] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/15/2019] [Indexed: 12/26/2022]
Abstract
Maribavir is an investigational drug being evaluated in transplant recipients with cytomegalovirus infection. To understand potential drug-drug interactions, we examined the effects of multiple doses of maribavir on cytochrome P450 (CYP) 2D6 and P-glycoprotein (P-gp) activity using probe substrates in healthy volunteers. During this phase 1 open-label study (NCT02775240), participants received the probe substrates digoxin (0.5 mg) and dextromethorphan (30 mg) before and after maribavir (400 mg twice daily for 8 days). Serial plasma samples were analyzed for digoxin, dextromethorpha, dextrorphan, and maribavir concentrations. Pharmacokinetic parameters were calculated (noncompartmental analysis) and analyzed with a linear mixed-effects model for treatment comparison to estimate geometric mean ratios (GMRs) and 90% confidence intervals (CIs). CYP2D6 polymorphisms were genotyped using polymerase chain reaction. Overall, 17 of 18 participants (94.4%) completed the study. All participants were genotyped as CYP2D6 intermediate/extensive metabolizers. GMR (90%CI) of digoxin Cmax , AUClast , and AUC0-∞ with and without maribavir was 1.257 (1.139-1.387), 1.187 (1.088-1.296), and 1.217 (1.110-1.335), respectively, outside the "no-effect" window (0.8-1.25). GMR (90%CI) of dextromethorphan AUClast and AUClast ratio of dextromethorphan/dextrorphan were 0.877 (0.692-1.112) and 0.901 (0.717-1.133), respectively, marginally outside the no-effect window, although large variability was observed in these pharmacokinetic parameters. Pharmacokinetic parameters of dextrorphan were unaffected. Maribavir inhibited P-gp activity but did not affect CYP2D6 activity. Maribavir's effect on the pharmacokinetics of P-gp substrates should be evaluated individually, and caution should be exercised with P-gp substrates with narrow therapeutic windows.
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Affiliation(s)
- Ivy H. Song
- Shire, a Takeda companyLexingtonMassachusettsUSA
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8
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Prytuła A, Cransberg K, Raes A. Drug-metabolizing enzymes CYP3A as a link between tacrolimus and vitamin D in renal transplant recipients: is it relevant in clinical practice? Pediatr Nephrol 2019; 34:1201-1210. [PMID: 30058048 DOI: 10.1007/s00467-018-4030-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 07/10/2018] [Accepted: 07/20/2018] [Indexed: 01/08/2023]
Abstract
CYP3A enzymes are involved in the metabolism of calcineurin inhibitor tacrolimus as well as vitamin D. In this review, we summarize the clinical aspects of CYP3A-mediated metabolism of tacrolimus and vitamin D with emphasis on the influence of single-nucleotide polymorphisms on tacrolimus disposition. We describe the utility of 4β hydroxycholesterol as a marker of CYP3A activity. Then, we discuss the possible interaction between calcineurin inhibitors and vitamin D in solid organ transplant recipients. Also, we review other mechanisms which may contribute to side effects of calcineurin inhibitors on bone. Lastly, suggestions for future research and clinical perspectives are discussed.
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Affiliation(s)
- Agnieszka Prytuła
- Paediatric Nephrology and Rheumatology Department, Ghent University Hospital, C Heymanslaan 10, 9000, Ghent, Belgium.
| | - Karlien Cransberg
- Paediatric Nephrology Department, Erasmus MC- Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Ann Raes
- Paediatric Nephrology and Rheumatology Department, Ghent University Hospital, C Heymanslaan 10, 9000, Ghent, Belgium.,Safepedrug Unit, Ghent, Belgium
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9
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Naito T, Ohshiro J, Sato H, Torikai E, Suzuki M, Ogawa N, Kawakami J. Relationships between concomitant biologic DMARDs and prednisolone administration and blood tacrolimus exposure or serum CYP3A4/5-related markers in rheumatoid arthritis patients. Clin Biochem 2019; 69:8-14. [DOI: 10.1016/j.clinbiochem.2019.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 04/19/2019] [Accepted: 05/06/2019] [Indexed: 11/29/2022]
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10
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Penzak SR, Rojas-Fernandez C. 4β-Hydroxycholesterol as an Endogenous Biomarker for CYP3A Activity: Literature Review and Critical Evaluation. J Clin Pharmacol 2019; 59:611-624. [PMID: 30748026 DOI: 10.1002/jcph.1391] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 01/25/2019] [Indexed: 12/13/2022]
Abstract
A number of cytochrome P450 (CYP)3A phenotyping probes have been used to characterize the drug interaction potential of new molecular entities; of these, midazolam has emerged as the gold standard. Recently, plasma 4β-hydroxycholesterol (4β-OHC), the metabolite of CYP3A-mediated cholesterol metabolism, has been championed as an endogenous biomarker for CYP3A, particularly during chronic conditions where CYP3A activity is altered by disease and in long-term treatment studies where midazolam administration is not optimal. Multiple studies in humans have shown that 4β-OHC can qualitatively differentiate among weak, moderate, and potent CYP3A induction when an inducer, typically rifampin, is administered for up to 2 weeks. Conversely, longer durations of CYP3A inhibitor administration (≥1 month) appear to be necessary to differentiate among weak, moderate, and potent CYP3A inhibitors. A number of studies have reported statistically significant linear relationships between 4β-OHC plasma concentrations (and 4β-OHC:cholesterol ratios) and midazolam clearance. However, sufficiently powered studies assessing the ability of 4β-OHC or 4β-OHC:cholesterol ratios to measure CYP3A activity (ie, predictive performance) have not been conducted to date. Additional limitations associated with 4β-OHC phenotyping include inability to detect acute changes in CYP3A activity, uncertainty with regard to its intestinal formation, ambiguity surrounding the role of CYP3A5 in its metabolism, and lack of clarity regarding the role of transporters in its disposition. As such, the data do not support the use of 4β-OHC or 4β-OHC:cholesterol ratios as an endogenous biomarker for CYP3A activity.
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Affiliation(s)
- Scott R Penzak
- Auburn University Harrison School of Pharmacy, Auburn, AL, USA
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11
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Campagne O, Mager DE, Tornatore KM. Population Pharmacokinetics of Tacrolimus in Transplant Recipients: What Did We Learn About Sources of Interindividual Variabilities? J Clin Pharmacol 2018; 59:309-325. [PMID: 30371942 DOI: 10.1002/jcph.1325] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/18/2018] [Indexed: 12/24/2022]
Abstract
Tacrolimus, a calcineurin inhibitor, is a common immunosuppressant prescribed after organ transplantation and has notable inter- and intrapatient pharmacokinetic variability. The sources of variability have been investigated using population pharmacokinetic modeling over the last 2 decades. This article provides an updated synopsis on published nonlinear mixed-effects analyses developed for tacrolimus in transplant recipients. The objectives were to establish a detailed overview of the current data and to investigate covariate relationships determined by the models. Sixty-three published analyses were reviewed, and data regarding the study design, modeling approach, and resulting findings were extracted and summarized. Most of the studies investigated tacrolimus pharmacokinetics in adult and pediatric renal and liver transplants after administration of the immediate-release formulation. Model structures largely depended on the study sampling strategy, with ∼50% of studies developing a 1-compartment model using trough concentrations and a 2-compartment model with delayed absorption from intensive sampling. The CYP3A5 genotype, as a covariate, consistently impacted tacrolimus clearance, and dosing adjustments were required to achieve similar drug exposure among patients. Numerous covariates were identified as sources of interindividual variability on tacrolimus pharmacokinetics with limited consistency across these studies, which may be the result of the study designs. Additional analyses are required to further evaluate the potential impact of these covariates and the clinical implementation of these models to guide tacrolimus dosing recommendations. This article may be useful for guiding the design of future population pharmacokinetic studies and provides recommendations for the selection of an existing optimal model to individualize tacrolimus therapy.
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Affiliation(s)
- Olivia Campagne
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA.,Faculty of Pharmacy, Universités Paris Descartes-Paris Diderot, Paris, France
| | - Donald E Mager
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Kathleen M Tornatore
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Immunosuppressive Pharmacology Research Program, Translational Pharmacology Research Core, NYS Center of Excellence in Bioinformatics and Life Sciences, University at Buffalo, Buffalo, NY, USA
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12
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Hole K, Heiberg PL, Gjestad C, Mehus LL, Rø Ø, Molden E. Elevated 4β-hydroxycholesterol/cholesterol ratio in anorexia nervosa patients. Pharmacol Res Perspect 2018; 6:e00430. [PMID: 30214813 PMCID: PMC6134200 DOI: 10.1002/prp2.430] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/21/2018] [Indexed: 12/23/2022] Open
Abstract
Recent studies have shown that the cytochrome P450 (CYP) 3A phenotype marker 4β-hydroxycholesterol/cholesterol (4βOHC/C) ratio is negatively correlated with body weight in healthy volunteers, and that obese patients have lower 4βOHC levels than healthy controls. However, 4βOHC/C ratio in underweight patients has yet to be reported. The aim of this study was to examine potential differences in CYP3A activity between underweight patients with anorexia nervosa and normal-weight volunteers by measuring plasma 4βOHC/C ratio. Furthermore, we wished to describe any association between body mass index (BMI) and 4βOHC/C ratio in underweight patients. A total of 20 underweight patients and 16 normal-weight volunteers were included in the study, all females. Underweight patients had a median 4βOHC/C ratio (molar ratio × 10-5) of 2.52 (range, 0.90-11.3) compared to 1.29 (0.56-2.09) in normal-weight subjects (Mann-Whitney P = 0.0005). 4βOHC/C ratio was negatively correlated with BMI in underweight patients (r = -0.56, P = 0.011), and in the whole study population (r = -0.67, P < 0.0001). This suggests that the negative correlation between 4βOHC/C and BMI, which has previously been reported between 4βOHC/C and body weight in healthy volunteers, extends to underweight patients. The findings indicate that CYP3A activity increases with decreasing BMI, resulting in higher CYP3A activity in underweight patients compared to normal-weight subjects. The potential clinical relevance of this needs to be studied further by comparing pharmacokinetics of drugs subjected to CYP3A-mediated metabolism in underweight vs. normal-weight individuals.
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Affiliation(s)
- Kristine Hole
- Center for PsychopharmacologyDiakonhjemmet HospitalOsloNorway
| | | | | | - Lise L. Mehus
- Department of Medicinal BiochemistryDiakonhjemmet HospitalOsloNorway
| | - Øyvind Rø
- Regional Department for Eating DisordersDivision of Mental Health and AddictionOslo University HospitalOsloNorway
- Division of Mental Health and AddictionInstitute of Clinical MedicineUniversity of OsloOsloNorway
| | - Espen Molden
- Center for PsychopharmacologyDiakonhjemmet HospitalOsloNorway
- Department of Pharmaceutical BiosciencesSchool of PharmacyUniversity of OsloOsloNorway
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13
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Comparison of CYP3A4-Inducing Capacity of Enzyme-Inducing Antiepileptic Drugs Using 4β-Hydroxycholesterol as Biomarker. Ther Drug Monit 2018; 40:463-468. [DOI: 10.1097/ftd.0000000000000518] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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14
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Kuypers DRJ, Vanhove T. Kuypers and Vanhove reply to 'Was 4β-hydroxycholesterol ever going to be a useful marker of CYP3A4 activity?' by Neuhoff and Tucker. Br J Clin Pharmacol 2018; 84:1622-1623. [PMID: 29691891 DOI: 10.1111/bcp.13592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/09/2018] [Accepted: 03/21/2018] [Indexed: 12/14/2022] Open
Affiliation(s)
- Dirk R J Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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15
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Hole K, Størset E, Olastuen A, Haslemo T, Kro GB, Midtvedt K, Åsberg A, Molden E. Recovery of CYP3A Phenotype after Kidney Transplantation. Drug Metab Dispos 2017; 45:1260-1265. [PMID: 28928137 DOI: 10.1124/dmd.117.078030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 09/15/2017] [Indexed: 11/22/2022] Open
Abstract
End-stage renal disease impairs drug metabolism via cytochrome P450 CYP3A; however, it is unclear whether CYP3A activity recovers after kidney transplantation. Therefore, the aim of this study was to evaluate the change in CYP3A activity measured as 4β-hydroxycholesterol (4βOHC) concentration after kidney transplantation. In total, data from 58 renal transplant recipients with 550 prospective 4βOHC measurements were included in the study. One sample per patient was collected before transplantation, and 2-12 samples per patient were collected 1-82 days after transplantation. The measured pretransplant 4βOHC concentrations ranged by >7-fold, with a median value of 22.8 ng/ml. Linear mixed-model analysis identified a 0.16-ng/ml increase in 4βOHC concentration per day after transplantation (P < 0.001), indicating a regain in CYP3A activity. Increasing estimated glomerular filtration rate after transplantation was associated with increasing 4βOHC concentration (P < 0.001), supporting that CYP3A activity increases with recovering uremia. In conclusion, this study indicates that CYP3A activity is regained subsequent to kidney transplantation.
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Affiliation(s)
- Kristine Hole
- Center for Psychopharmacology, Diakonhjemmet Hospital (K.H., T.H., E.M.), Department of Transplantation Medicine (E.S., K.M., A.Å.) and Department of Microbiology (G.B.K.), Oslo University Hospital Rikshospitalet, and Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo (A.O., A.Å., E.M.), Oslo, Norway
| | - Elisabet Størset
- Center for Psychopharmacology, Diakonhjemmet Hospital (K.H., T.H., E.M.), Department of Transplantation Medicine (E.S., K.M., A.Å.) and Department of Microbiology (G.B.K.), Oslo University Hospital Rikshospitalet, and Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo (A.O., A.Å., E.M.), Oslo, Norway
| | - Ane Olastuen
- Center for Psychopharmacology, Diakonhjemmet Hospital (K.H., T.H., E.M.), Department of Transplantation Medicine (E.S., K.M., A.Å.) and Department of Microbiology (G.B.K.), Oslo University Hospital Rikshospitalet, and Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo (A.O., A.Å., E.M.), Oslo, Norway
| | - Tore Haslemo
- Center for Psychopharmacology, Diakonhjemmet Hospital (K.H., T.H., E.M.), Department of Transplantation Medicine (E.S., K.M., A.Å.) and Department of Microbiology (G.B.K.), Oslo University Hospital Rikshospitalet, and Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo (A.O., A.Å., E.M.), Oslo, Norway
| | - Grete Birkeland Kro
- Center for Psychopharmacology, Diakonhjemmet Hospital (K.H., T.H., E.M.), Department of Transplantation Medicine (E.S., K.M., A.Å.) and Department of Microbiology (G.B.K.), Oslo University Hospital Rikshospitalet, and Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo (A.O., A.Å., E.M.), Oslo, Norway
| | - Karsten Midtvedt
- Center for Psychopharmacology, Diakonhjemmet Hospital (K.H., T.H., E.M.), Department of Transplantation Medicine (E.S., K.M., A.Å.) and Department of Microbiology (G.B.K.), Oslo University Hospital Rikshospitalet, and Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo (A.O., A.Å., E.M.), Oslo, Norway
| | - Anders Åsberg
- Center for Psychopharmacology, Diakonhjemmet Hospital (K.H., T.H., E.M.), Department of Transplantation Medicine (E.S., K.M., A.Å.) and Department of Microbiology (G.B.K.), Oslo University Hospital Rikshospitalet, and Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo (A.O., A.Å., E.M.), Oslo, Norway
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital (K.H., T.H., E.M.), Department of Transplantation Medicine (E.S., K.M., A.Å.) and Department of Microbiology (G.B.K.), Oslo University Hospital Rikshospitalet, and Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo (A.O., A.Å., E.M.), Oslo, Norway
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16
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Gjestad C, Haslemo T, Andreassen OA, Molden E. 4β-Hydroxycholesterol level significantly correlates with steady-state serum concentration of the CYP3A4 substrate quetiapine in psychiatric patients. Br J Clin Pharmacol 2017; 83:2398-2405. [PMID: 28585378 DOI: 10.1111/bcp.13341] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 05/07/2017] [Accepted: 05/27/2017] [Indexed: 01/03/2023] Open
Abstract
AIM 4β-Hydroxycholesterol (4βOHC) is sensitive towards induction or inhibition of CYP3A4, but its potential usefulness as a dosing biomarker remains to be demonstrated. The aim of this study was to investigate the correlation between 4βOHC levels and steady-state concentrations (Css) of quetiapine, a CYP3A4 substrate with high presystemic metabolism, in psychiatric patients. METHODS Serum samples from 151 patients treated with quetiapine as immediate release (IR; n = 98) or slow release (XR; n = 53) tablets were included for analysis of 4βOHC. In all patients, Css of quetiapine had been measured at trough level, i.e. 10-14 and 17-25 h post-dosing for IR and XR tablets, respectively. Correlations between 4βOHC levels and dose-adjusted Css (C/D ratios) of quetiapine were tested by univariate (Spearman's) and multivariate (multiple linear regression) analyses. Gender, age (≥60 vs. <60 years) and tablet formulation were included as potential covariates in the multivariate analysis. RESULTS Correlations between 4βOHC levels and quetiapine C/D ratios were highly significant both for IR- and XR-treated patients (P < 0.0001). Estimated Spearman r values were -0.47 (95% confidence interval -0.62, -0.30) and -0.56 (-0.72, -0.33), respectively. The relationship between 4βOHC level and quetiapine C/D ratio was also significant in the multiple linear regression analysis (P < 0.001), including gender (P = 0.023) and age (P = 0.003) as significant covariates. CONCLUSIONS The present study shows that 4βOHC level is significantly correlated with steady-state concentration of quetiapine. This supports the potential usefulness of 4βOHC as a phenotype biomarker for individualized dosing of quetiapine and other drugs where systemic exposure is mainly determined by CYP3A4 metabolism.
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Affiliation(s)
- Caroline Gjestad
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Tore Haslemo
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Ole A Andreassen
- NORMENT, KG Jebsen Centre for Psychosis Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway.,Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway
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17
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Vanhove T, Hasan M, Annaert P, Oswald S, Kuypers DRJ. Pretransplant 4β-hydroxycholesterol does not predict tacrolimus exposure or dose requirements during the first days after kidney transplantation. Br J Clin Pharmacol 2017; 83:2406-2415. [PMID: 28603840 DOI: 10.1111/bcp.13343] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/29/2017] [Accepted: 06/07/2017] [Indexed: 12/16/2022] Open
Abstract
AIMS The CYP3A metric 4β-hydroxycholesterol (4βOHC) has been shown to correlate with tacrolimus steady-state apparent oral clearance (CL/F). Recently, pretransplant 4βOHC was shown not to predict tacrolimus CL/F after transplantation in a cohort of renal recipients (n = 79). The goal of the current study was determine whether these findings could be validated in a substantially larger cohort. METHODS In a retrospective analysis of 279 renal recipients, tacrolimus trough concentrations (C0), daily dose, haematocrit and other relevant covariates were registered every day for the first 14 days after transplantation. 4βOHC and cholesterol were quantified on plasma collected immediately pretransplant using liquid chromatography tandem-mass spectrometry. Patients were genotyped for CYP3A5*1 and CYP3A4*22. RESULTS A total of 3551 tacrolimus C0 concentrations were registered. In a linear mixed model for the 14-day period, determinants of tacrolimus C0 were CYP3A5 genotype, haematocrit, age and weight (overall R2 = 0.179). Determinants of daily dose were CYP3A5 genotype, age, methylprednisolone dose, tacrolimus formulation, ALT and estimated glomerular filtration rate (overall R2 = 0.242). Considering each of the first 5 days separately, 4βOHC had a limited effect on tacrolimus C0 on day 3 only (-1.00 ng ml-1 per ln, P = 0.035) but not on any other day, and no effect on dose or C0/dose. During the first 5 days, haematocrit and age, which were previously established as determinants of tacrolimus disposition under steady-state conditions, never explained more than 17.7% of between-subject variability in tacrolimus C0/dose. CONCLUSIONS The CYP3A metric 4βOHC cannot be used to predict tacrolimus dose requirements in the first days after transplantation.
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Affiliation(s)
- Thomas Vanhove
- Department of Microbiology and Immunology, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Mahmoud Hasan
- Department of Clinical Pharmacology, Center of Drug Absorption and Transport (C_DAT), University Hospital Greifswald, Greifswald, Germany
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - Stefan Oswald
- Department of Clinical Pharmacology, Center of Drug Absorption and Transport (C_DAT), University Hospital Greifswald, Greifswald, Germany
| | - Dirk R J Kuypers
- Department of Microbiology and Immunology, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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18
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Størset E, Hole K, Midtvedt K, Bergan S, Molden E, Åsberg A. Response to: 'Response to: Bodyweight-adjustments introduce significant correlations between CYP3A metrics and tacrolimus clearance'. Br J Clin Pharmacol 2017; 83:1357-1358. [PMID: 28374426 DOI: 10.1111/bcp.13276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 02/27/2017] [Indexed: 01/05/2023] Open
Affiliation(s)
- Elisabet Størset
- Department of Transplant Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristine Hole
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Karsten Midtvedt
- Department of Transplant Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Stein Bergan
- Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway.,Department of Pharmacology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway.,Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway
| | - Anders Åsberg
- Department of Transplant Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Oslo, Norway
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19
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Størset E, Hole K, Midtvedt K, Bergan S, Molden E, Åsberg A. The CYP3A biomarker 4β-hydroxycholesterol does not improve tacrolimus dose predictions early after kidney transplantation. Br J Clin Pharmacol 2017; 83:1457-1465. [PMID: 28146606 DOI: 10.1111/bcp.13248] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 01/16/2017] [Accepted: 01/29/2017] [Indexed: 12/22/2022] Open
Abstract
AIMS Tacrolimus is a cornerstone in modern immunosuppressive therapy after kidney transplantation. Tacrolimus dosing is challenged by considerable pharmacokinetic variability, both between patients and over time after transplantation, partly due to variability in cytochrome P450 3A (CYP3A) activity. The aim of this study was to assess the value of the endogenous CYP3A marker 4β-hydroxycholesterol (4βOHC) for tacrolimus dose individualization early after kidney transplantation. METHODS Data were obtained from 79 adult kidney transplant recipients who contributed a total of 625 4βOHC measurements and 1999 tacrolimus whole blood concentrations during the first 2 months after transplantation. The relationships between 4βOHC levels and individual estimates of tacrolimus apparent plasma clearance (CL/Fplasma ) at different time points after transplantation were investigated using scatterplots and population pharmacokinetic modelling. RESULTS There was no significant correlation between pre-transplant 4βOHC levels and tacrolimus CL/Fplasma the first week (r = 0.19 [95% CI -0.03-0.40]) or between 4βOHC and tacrolimus CL/Fplasma 1 week (r = 0.20 [-0.11-0.47]), 4 weeks (r = 0.21 [-0.07-0.46]) or 2 months (r = 0.24 [-0.03-0.48]) after transplantation (P ≥ 0.06). In the population analysis, time-varying 4βOHC was not a statistically significant covariate on tacrolimus CL/Fplasma , neither in terms of absolute values (P = 0.11) nor in terms of changes from baseline (P = 0.17). 4βOHC values increased between 1 week and 2 months after transplantation (median change +57% [IQR +22-83%], P < 0.001), indicating increasing CYP3A activity. Contradictorily, tacrolimus CL/Fplasma decreased over the same period (median change -13% [IQR -3 to -26%], P < 0.001). CONCLUSIONS 4βOHC does not appear to have a clinical potential to improve individualization of tacrolimus doses early after kidney transplantation.
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Affiliation(s)
- Elisabet Størset
- Department of Transplant Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Norway
| | - Kristine Hole
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
| | - Karsten Midtvedt
- Department of Transplant Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Stein Bergan
- Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Norway.,Department of Pharmacology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Espen Molden
- Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway.,Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Norway
| | - Anders Åsberg
- Department of Transplant Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Department of Pharmaceutical Biosciences, School of Pharmacy, University of Oslo, Norway
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