Pharmacokinetic herb-drug interaction between ginger and crizotinib

Lung cancer, comorbidities, and medication: the infernal trio

Most patients with lung cancer are smokers and are of advanced age. They are therefore at high risk of having age- and lifestyle-related comorbidities. These comorbidities are subject to treatment or even polypharmacy. There is growing evidence of a link between lung cancer, comorbidities and medications. The relationships between these entities are complex. The presence of comorbidities and their treatments influence the time of cancer diagnosis, as well as the diagnostic and treatment strategy. On the other hand, cancer treatment may have an impact on the patient's comorbidities such as renal failure, pneumonitis or endocrinopathies. This review highlights how some comorbidities may have an impact on lung cancer presentation and may require treatment adjustments. Reciprocal influences between the treatment of comorbidities and anticancer therapy will also be discussed.

Modulation of Hepatic Functions by Chicory (Cichorium intybus L.) Extract: Preclinical Study in Rats

The liver is important in detoxifying organisms from xenobiotics, supporting immune functions, and metabolizing lipids and glucose. In addition, a growing number of drug-induced liver injuries and diseases associated with liver dysfunction make the development of phytodrugs targeting multiple liver functions particularly crucial. Therefore, we investigated the effects of a novel chicory extract prepared from aerial parts of the wild Cichorium intybus L. plant (CE) on liver enzymes and on lipid and glucose metabolism in rats with acute liver injury or hyperlipidemia. A single subcutaneous injection of mercury chloride induced an acute liver injury. Hyperlipidemia was induced by a single intraperitoneal injection of Tween-80 or by feeding rats with cholesterol and mercazolil for 28 days. Under varying regimens, the experimental rats received 100 mg/kg b.w. or 500 mg/kg b.w. of CE. CE treatment ameliorated acute liver injury by reducing liver enzyme activity, bilirubin, glucose, and lipid levels. Treatment of hyperlipidemic rats with CE effectively reduced serum lipid and glucose levels. The data obtained in this study suggest that chicory-based phytodrugs may be used to effectively treat acute liver injury and for the prophylaxis or treatment of diseases such as hyperlipidemia, type 2 diabetes, and metabolic syndrome. Clinical trials are needed to prove the effectiveness of chicory extract in human patients.

Concurrent use of herbal and prescribed medicine by patients in primary health care clinics, South Africa

BACKGROUND

The use of herbal medicine (HM) as a self-management practice for treating various diseases has gained popularity worldwide. Consumers co-administer herbal products with conventional medicine without the knowledge of possible herb-drug interaction (HDI).

AIM

This study aimed to assess patients' perception and use of HM and their knowledge of HDI.

SETTING

Participants attending primary health care (PHC) clinics in three provinces (Gauteng, Mpumalanga and Free State), South Africa, were recruited.

METHODS

Focus group discussions comprising a total of thirty (N = 30) participants were conducted using a semi-structured interview guide. Discussions were audio-recorded and then transcribed verbatim. Data were analysed using thematic content analysis.

RESULTS

Reasons for using HM, sources of information on HM, co-administration of HM and prescribed medicine, disclosure of the use of HM, PHC nurses' attitudes and not having time to engage were frequently discussed. Respondents' lack of knowledge and perceptions about HDI and their dissatisfaction with prescribed medicine because of experienced side effects were also discussed.

CONCLUSION

Because of the lack of discussions and non-disclosure about HM in PHC clinics, patients are at risk of experiencing HDIs. Primary health care providers should regularly enquire about HM use on every patient, to identify and prevent HDIs. The lack of knowledge about HDIs by patients further compromises the safety of HM.Contribution: The results highlighted the lack of knowledge of HDI by patients thus assisting the healthcare stakeholders in South Africa to implement measures to educate patients attending PHC clinics.

Evaluation of the Herb-Drug Interaction (HDI) Potential of Zingiber officinale and Its Major Phytoconstituents

Ginger is currently one of the most popular herbs commonly added to diverse foods, beverages, and dietary supplements. We evaluated the ability of a well-characterized ginger extract, and several of its phytoconstituents, to activate select nuclear receptors as well as modulate the activity of various cytochrome P450s and ATP-binding cassette (ABC) transporters because phytochemical-mediated modulation of these proteins underlies many clinically relevant herb-drug interactions (HDI). Our results revealed ginger extract activated the aryl hydrocarbon receptor (AhR) in AhR-reporter cells and pregnane X receptor (PXR) in intestinal and hepatic cells. Among the phytochemicals investigated, (S)-6-gingerol, dehydro-6-gingerdione, and (6S,8S)-6-gingerdiol activated AhR, while 6-shogaol, 6-paradol, and dehydro-6-gingerdione activated PXR. Enzyme assays showed that ginger extract and its phytochemicals dramatically inhibited the catalytic activity of CYP3A4, 2C9, 1A2, and 2B6, and efflux transport capabilities of P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP). Dissolution studies with ginger extract conducted in biorelevant simulated intestinal fluid yielded (S)-6-gingerol and 6-shogaol concentrations that could conceivably exceed cytochrome P450 (CYP) IC50 values when consumed in recommended doses. In summary, overconsumption of ginger may disturb the normal homeostasis of CYPs and ABC transporters, which in turn, may elevate the risk for HDIs when consumed concomitantly with conventional medications.

Herb-drug interactions between Panax notoginseng or its biologically active compounds and therapeutic drugs: A comprehensive pharmacodynamic and pharmacokinetic review

ETHNOPHARMACOLOGICAL RELEVANCE

Herbs, along with the use of herb-drug interactions (HDIs) to combat diseases, are increasing in popularity worldwide. HDIs have two effects: favorable interactions that tend to improve therapeutic outcomes and/or minimize the toxic effects of drugs, and unfavorable interactions aggravating the condition of patients. Panax notoginseng (Burk.) F.H. Chen is a medicinal plant that has long been commonly used in traditional Chinese medicine to reduce swelling, relieve pain, clear blood stasis, and stop bleeding. Numerous studies have demonstrated the existence of intricate pharmacodynamic (PD) and pharmacokinetic (PK) interactions between P. notoginseng and conventional drugs. However, these HDIs have not been systematically summarized.

AIM OF THE REVIEW

To collect the available literature on the combined applications of P. notoginseng and drugs published from 2005 to 2022 and summarize the molecular mechanisms of interactions to circumvent the potential risks of combination therapy.

MATERIALS AND METHODS

This work was conducted by searching PubMed, Scopus, Web of Science, and CNKI databases. The search terms included "notoginseng", "Sanqi", "drug interaction," "synergy/synergistic", "combination/combine", "enzyme", "CYP", and "transporter".

RESULTS

P. notoginseng and its bioactive ingredients interact synergistically with numerous drugs, including anticancer, antiplatelet, and antimicrobial agents, to surmount drug resistance and side effects. This review elaborates on the molecular mechanisms of the PD processed involved. P. notoginseng shapes the PK processes of the absorption, distribution, metabolism, and excretion of other drugs by regulating metabolic enzymes and transporters, mainly cytochrome P450 enzymes and P-glycoprotein. This effect is a red flag for drugs with a narrow therapeutic window. Notably, amphipathic saponins in P. notoginseng act as auxiliary materials in drug delivery systems to enhance drug solubility and absorption and represent a new entry point for studying interactions.

CONCLUSION

This article provides a comprehensive overview of HDIs by analyzing the results of the in vivo and in vitro studies on P. notoginseng and its bioactive components. The knowledge presented here offers a scientific guideline for investigating the clinical importance of combination therapies. Physicians and patients need information on possible interactions between P. notoginseng and other drugs, and this review can help them make scientific predictions regarding the consequences of combination treatments.

Screening of medicinal plants for possible herb-drug interactions through modulating nuclear receptors, drug-metabolizing enzymes and transporters

ETHNOPHARMACOLOGICAL RELEVANCE

The last three decades have witnessed a surge in popularity and consumption of herbal products. An unintended consequence of such popularity is that chronic consumption of these products can often modulate the functions of various proteins involved in drug disposition and may, in turn, impose risks for herb-drug interactions (HDIs), leading to serious adverse health outcomes. Identifying plants that may give rise to clinically relevant HDIs is essential, and proactive dissemination of such research outcomes is necessary for researchers, clinicians, and average consumers.

AIM OF THE STUDY

The main objective of this study was to evaluate the HDI potential of plants commonly used as ingredients in many herbal products, including BDS.

MATERIALS AND METHODS

The dried material of 123 plants selected from the NCNPR repository was extracted with 95% ethanol. The extracts were screened for agonistic effects on nuclear receptors (PXR and AhR) by reporter gene assays in PXR-transfected HepG2 and AhR-reporter cells. For cytochrome P450 enzyme (CYP) inhibition studies, CYP450 baculosomes were incubated with enzyme-specific probe substrates by varying concentrations of extracts. The inhibitory effect on the efflux transporter P-glycoprotein (P-gp) was investigated via rhodamine (Rh-123) uptake assay in P-gp overexpressing MDR1-MDCK cells.

RESULTS

Out of 123 plants, 16 increased transcriptional activity of human PXR up to 4 to 7-fold at 60 μg/mL, while 18 plants were able to increase AhR activity up to 10 to 40-fold at 30 μg/mL. Thirteen plants inhibited the activity of CYP3A4, while 10 plants inhibited CYP1A2 activity with IC₅₀ values in the range of 1.3-10 μg/mL. Eighteen plants (at 50 μg/mL) increased intracellular accumulation of Rh-123 (>150%) in MDR1-MDCK cells. Additionally, other plants tested in this study were able to activate PXR, AhR, or both to lesser extents, and several inhibited the catalytic activity of CYPs at higher concentrations (IC₅₀ >10 μg/mL).

CONCLUSIONS

The results indicate that prolonged or excessive consumption of herbal preparations rich in such plants (presented in Figs. 1a, 2a, 3a, 4a, and 5a) may pose a risk for CYP- and P-gp-mediated HDIs, leading to unwanted side effects due to the altered pharmacokinetics of concomitantly ingested medications.

Polyphenol-Rich Ginger (Zingiber officinale) for Iron Deficiency Anaemia and Other Clinical Entities Associated with Altered Iron Metabolism

Ginger (Zingiber officinale) is rich in natural polyphenols and may potentially complement oral iron therapy in treating and preventing iron deficiency anaemia (IDA). This narrative review explores the benefits of ginger for IDA and other clinical entities associated with altered iron metabolism. Through in vivo, in vitro, and limited human studies, ginger supplementation was shown to enhance iron absorption and thus increase oral iron therapy's efficacy. It also reduces oxidative stress and inflammation and thus protects against excess free iron. Ginger's bioactive polyphenols are prebiotics to the gut microbiota, promoting gut health and reducing the unwanted side effects of iron tablets. Moreover, ginger polyphenols can enhance the effectiveness of erythropoiesis. In the case of iron overload due to comorbidities from chronic inflammatory disorders, ginger can potentially reverse the adverse impacts and restore iron balance. Ginger can also be used to synthesise nanoparticles sustainably to develop newer and more effective oral iron products and functional ingredients for IDA treatment and prevention. Further research is still needed to explore the applications of ginger polyphenols in iron balance and anaemic conditions. Specifically, long-term, well-designed, controlled trials are required to validate the effectiveness of ginger as an adjuvant treatment for IDA.

Herb-anticancer drug interactions in real life based on VigiBase, the WHO global database

Cancer patients could combine herbal treatments with their chemotherapy. We consulted VigiBase, a WHO database of individual case safety reports (ICSRs) which archives reports of suspected Adverse Drug Reactions (ADRs) when herbal products are used in conjunction with anti-cancer treatment. We focused on the possible interactions between antineoplastic (L01 ATC class) or hormone antagonists (L02B ATC class) with 10 commonly used herbs (pineapple, green tea, cannabis, black cohosh, turmeric, echinacea, St John’s wort, milk thistle and ginger) to compare ADRs described in ICSRs with the literature. A total of 1057 ICSRs were extracted from the database but only 134 were complete enough (or did not concern too many therapeutic lines) to keep them for analysis. Finally, 51 rationalizable ICSRs could be explained, which led us to propose a pharmacokinetic or pharmacodynamic interaction mechanism. Reports concerned more frequently women and half of the rationalizable ICSRs involved Viscum album and Silybum marianum. 5% of the ADRs described could have been avoided if clinicians had had access to the published information. It is also important to note that in 8% of the cases, the ADRs observed were life threatening. Phytovigilance should thus be considered more by health care professionals to best treat cancer patients and for better integrative care.

Nonselective Cell Necrosis Mediated by the Total Flavones of Penthorum Chinensis Pursh and Thonningianin-A in Human Hepatic and Hepatoma Cells

Penthorum chinensis Pursh (PCP), family Penthoraceae, has been used for hundreds of years in China. With the launch of PCP tablets, clinical applications focused on liver fibrosis and hepatocarcinoma. The purpose of this research was to explore the selectivity and toxicity of the active pharmacodynamic ingredients of PCP in vitro. The total flavones of PCP (TFPCE) and thonningianin-A (Th-A), a major flavone in TFPCE, were investigated on the cell death patterns in human hepatoma cells (HepG2) and human hepatic cells (LO2), followed by a concentration detection of LDH in the supernatants. Apoptosis and necrosis detection kits were used to validate the patterns of cell death caused by TFPCE and Th-A. Finally, the cytotoxicity of both TFPCE and Th-A were reproduced in the colorectal adenocarcinoma cells (NCI-H716). The results indicated that TFPCE inhibits the cell viability of HepG2 cells at a concentration lower than 25 μg/mL. Alternatively, the cell viability of LO2 cells dramatically decreased in the treatment of TFPCE at 25 μg/mL. The effects of Th-A on the cell viability of HepG2 cells and LO2 cells were consistent with TFPCE. LDH detection indicated that TFPCE and Th-A increased the LDH concentration of the supernatants in a dose-dependent way, indicating the pattern of cell necrosis. Fluorescence staining verified the necrosis cell death caused by TFPCE and Th-A. A dose-dependent tendency was obtained in NCI-H716 cells, indicating that the cell viability of NCI-H716 cells was significantly suppressed with the treatment of TFPCE and Th-A. Our results bring the potential toxicity of PCP to the forefront of public attention. Therefore, the clinical application of P chinensis is required to focus more on its cytotoxic effect.

Herb-Drug Interaction in Inflammatory Diseases: Review of Phytomedicine and Herbal Supplements

Many people worldwide use plant preparations for medicinal purposes. Even in industrialized regions, such as Europe, where conventional therapies are accessible for the majority of patients, there is a growing interest in and usage of phytomedicine. Plant preparations are not only used as alternative treatment, but also combined with conventional drugs. These combinations deserve careful contemplation, as the complex mixtures of bioactive substances in plants show a potential for interactions. Induction of CYP enzymes and pGP by St John's wort may be the most famous example, but there is much more to consider. In this review, we shed light on what is known about the interactions between botanicals and drugs, in order to make practitioners aware of potential drug-related problems. The main focus of the article is the treatment of inflammatory diseases, accompanied by plant preparations used in Europe. Several of the drugs we discuss here, as basal medication in chronic inflammatory diseases (e.g., methotrexate, janus kinase inhibitors), are also used as oral tumor therapeutics.

Use of Modeling and Simulation to Predict the Influence of Triazole Antifungal Agents on the Pharmacokinetics of Crizotinib

Crizotinib is used for the treatment of c-ros oncogene 1-positive advanced non-small-cell lung cancer. Triazole antifungal agents are widely used for invasive fungal infections in clinical practice. To predict the potential influence of different triazoles (voriconazole, fluconazole, and itraconazole) on the pharmacokinetics of crizotinib by modeling and simulation the physiologically based pharmacokinetic models were established and validated in virtual cancer subjects through Simcyp software based on the essential physicochemical properties and pharmacokinetic data collected. The validated physiologically based pharmacokinetic models were applied to predict the drug-drug interactions between crizotinib and different triazoles (voriconazole, fluconazole, or itraconazole) in patients with cancer. Crizotinib and triazole antifungal agents were administered orally. The predicted plasma concentration vs time profiles of crizotinib, voriconazole, fluconazole, and itraconazole showed good agreement with observed, respectively. The geometric mean area under the plasma concentration-time curve (AUC) of crizotinib was increased by 84%, 58%, and 79% when coadministered with voriconazole, fluconazole, or itraconazole at multiple doses, respectively. The drug-drug interaction results showed increased pharmacokinetic exposure (maximum plasma concentration and area under the plasma concentration-time curve) of crizotinib when coadministrated with different triazoles (voriconazole > itraconazole > fluconazole). Among the 3 triazoles, voriconazole exhibited the most significant influence on the pharmacokinetic exposure of crizotinib. In clinic, adverse drug reactions and toxicity related to crizotinib should be carefully monitored, and therapeutic drug monitoring for crizotinib is recommended to guide dosing and optimize treatment when coadministered with voriconazole, fluconazole, or itraconazole.

Pharmacokinetic herb-drug interaction between ginger and crizotinib

The use of complementary and alternative medicine at least once during or after cancer treatment has increased over the past years from an estimated 25% in the 1970s and 1980s to more than 32% in the 1990s and to 49% after 2000. The risk of herb-drug interaction is therefore increasingly recognized as a public health problem. To the best of our knowledge, we report here the first case of interaction between ginger and anticancer drug, with serious consequences for the patient. There is an urgent need regarding complementary and alternative medicine: Both clinicians and patients should be aware of the potential interactions between herbs and prescribed drugs.

Population Pharmacokinetics of Erlotinib in Patients With Non-small Cell Lung Cancer: Its Application for Individualized Dosing Regimens in Older Patients

PURPOSE

Erlotinib is an oral first-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor approved for non-small cell lung cancers (NSCLC) with EGFR-activating mutations. Older patients experience more toxicities compared with younger patients at the standard recommended dose of 150 mg once daily. The aims of this study were to describe the pharmacokinetic profile of erlotinib in unselected patients with NSCLC, to quantify and explain its variability, to challenge the standard recommended dose in older patients, and to propose clinical recommendations for the therapeutic management of patients taking erlotinib.

METHODS

A population pharmacokinetic model was developed using erlotinib plasma concentrations collected from patients with NSCLC participating in a routine therapeutic drug monitoring program (with the nonlinear mixed effect modeling program NONMEM). Relevant demographic characteristics, clinical factors, and co-medications were tested as potential covariates. An independent dataset was used for model validation. Simulations based on the final model allowed comparison of expected erlotinib concentrations under standard and alternative dosing regimens for smokers and for several age groups.

FINDINGS

A total of 481 erlotinib plasma concentrations from 91 patients with NSCLC were used for model building and 239 plasma drug concentrations from 107 patients for model validation. A one-compartment model with first-order absorption and elimination provided the best fit. Average erlotinib CL/F with interindividual variability (%CV) was 3.8 L/h (41.5%), and V/F was 166 L (53.8%). The absorption rate constant was 1.48 h^-1. The external validation showed a negligible bias of -4% (95% CI, -7 to -1) in the individual predictions, with a precision of 23%. Current smoking and use of proton pump inhibitors were associated with higher CL/F, whereas age was associated with lower CL/F. Simulations suggest that a lower dose in older patients would decrease the risk of overexposure.

IMPLICATIONS

This large cohort study confirms the substantial interindividual variability in erlotinib plasma exposure and the impact of smoking and proton pump inhibitor intake. This large variability in erlotinib pharmacokinetics indicates that the standard recommended dose of 150 mg once daily is likely not appropriate to reach the expected concentrations in each patient. Concentration monitoring should be performed to individually adjust the erlotinib dosing regimen. The observed decrease in erlotinib CL/F with age suggests that a lower starting daily dose of 100 mg with concentration-guided dose adjustment would prevent overexposure and potential toxicity in older frail patients with co-morbidities.