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Kvitne KE, Hjelmesæth J, Hovd M, Sandbu R, Johnson LK, Andersson S, Karlsson C, Christensen H, Jansson-Löfmark R, Åsberg A, Robertsen I. Oral Drug Dosing After Gastric Bypass and Diet-Induced Weight Loss: Simpler Than We Think? Lessons Learned From the COCKTAIL Study. Clin Pharmacol Ther 2024. [PMID: 38771070 DOI: 10.1002/cpt.3307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/02/2024] [Indexed: 05/22/2024]
Abstract
This article summarizes the lessons learned from the COCKTAIL study: an open, three-armed, single-center study including patients with obesity scheduled for treatment with Roux-en-Y gastric bypass (RYGB) or nonsurgical calorie restriction, and a normal- to overweight control group. The clinical implications of the results from multiple peer-reviewed articles describing the effects of RYGB, severe caloric restriction, weight loss, and type 2 diabetes on the in vivo activity and protein expression of drug-metabolizing enzymes (cytochrome P450 (CYP) 1A2, 2C9, 2C19, and 3A) and transporters (DMETs; organic anion-transporting polypeptide (OATP) 1B1 and P-glycoprotein (P-gp)) are discussed in the perspective of three clinically relevant questions: (1) How should clinicians get the dose right in patients after RYGB? (2) Will drug disposition in patients with obesity be normalized after successful weight loss? (3) Are dose adjustments needed according to obesity and diabetes status? Overall, RYGB seems to have a lower impact on drug disposition than previously assumed, but clinicians should pay close attention to drugs with a narrow therapeutic range or where a high maximum drug concentration may be problematic. Whether obesity-related alterations of DMETs normalize with substantial weight loss depends on the DMET in question. Obesity and diabetes downregulate the in vivo activity of CYP2C19 and CYP3A (only obesity) but whether substrate drugs should be dose adjusted is also dependent on other factors that influence clearance, that is, liver blood flow and protein binding. Finally, we recommend frequent and individualized follow-up due to high inter- and intraindividual variability in these patients, particularly following RYGB.
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Affiliation(s)
| | - Jøran Hjelmesæth
- Department of Endocrinology, Obesity and Nutrition, Vestfold Hospital Trust, Tønsberg, Norway
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus Hovd
- Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Rune Sandbu
- Department of Endocrinology, Obesity and Nutrition, Vestfold Hospital Trust, Tønsberg, Norway
| | - Line Kristin Johnson
- Department of Endocrinology, Obesity and Nutrition, Vestfold Hospital Trust, Tønsberg, Norway
| | - Shalini Andersson
- Oligonucleotide Discovery, Discovery Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Cecilia Karlsson
- Late-Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Rasmus Jansson-Löfmark
- DMPK, Research and Early Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anders Åsberg
- Department of Pharmacy, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Ida Robertsen
- Department of Pharmacy, University of Oslo, Oslo, Norway
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Dietrich CG, Geier A. What is the impact of metabolic dysfunction-associated steatotic liver disease on drug transport and metabolism? Expert Opin Drug Metab Toxicol 2024; 20:107-110. [PMID: 38412106 DOI: 10.1080/17425255.2024.2324015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/23/2024] [Indexed: 02/29/2024]
Affiliation(s)
| | - Andreas Geier
- Division of Hepatology, Department of Medicine II, University Hospital Wuerzburg (UKW), Würzburg, Germany
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Bruijn N, van Lohuizen R, Boron M, Fitzek M, Gabriele F, Giuliani G, Melgarejo L, Řehulka P, Sebastianelli G, Triller P, Vigneri S, Özcan B, van den Brink AM. Influence of metabolic state and body composition on the action of pharmacological treatment of migraine. J Headache Pain 2024; 25:20. [PMID: 38347465 PMCID: PMC10863119 DOI: 10.1186/s10194-024-01724-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/22/2024] [Indexed: 02/15/2024] Open
Abstract
Migraine is a disabling neurovascular disorder among people of all ages, with the highest prevalence in the fertile years, and in women. Migraine impacts the quality of life of affected individuals tremendously and, in addition, it is associated with highly prevalent metabolic diseases, such as obesity, diabetes mellitus and thyroid dysfunction. Also, the clinical response to drugs might be affected in patients with metabolic disease due to body composition and metabolic change. Therefore, the efficacy of antimigraine drugs could be altered in patients with both migraine and metabolic disease. However, knowledge of the pharmacology and the related clinical effects of antimigraine drugs in patients with metabolic disease are limited. Therefore, and given the clinical relevance, this article provides a comprehensive overview of the current research and hypotheses related to the influence of metabolic state and body composition on the action of antimigraine drugs. In addition, the influence of antimigraine drugs on metabolic functioning and, vice versa, the influence of metabolic diseases and its hormonal modulating medication on migraine activity is outlined. Future exploration on personalizing migraine treatment to individual characteristics is necessary to enhance therapeutic strategies, especially given its increasing significance in recent decades.
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Affiliation(s)
- Noor Bruijn
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Romy van Lohuizen
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Malgorzata Boron
- Department of Neurology, University Hospital, Wroclaw Medical University, Wroclaw, Poland
| | - Mira Fitzek
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Francesca Gabriele
- Department of Applied Clinical Sciences and Biotechnology, Neuroscience Section, University of L'Aquila, L'Aquila, Italy
| | - Giada Giuliani
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Laura Melgarejo
- Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Pavel Řehulka
- St. Anne's University Hospital, Faculty of Medicine Masaryk University Czech Republic, Brno, Czech Republic
| | - Gabriele Sebastianelli
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome Polo Pontino ICOT, Latina, Italy
| | - Paul Triller
- Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Simone Vigneri
- Casa Di Cura Santa Maria Maddalena, Neurology and Neurophysiology Service, Occhiobello, Italy
| | - Behiye Özcan
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Antoinette Maassen van den Brink
- Department of Internal Medicine, Division of Vascular Medicine and Pharmacology, Erasmus MC, Erasmus University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
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4
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Armani S, Geier A, Forst T, Merle U, Alpers DH, Lunnon MW. Effect of changes in metabolic enzymes and transporters on drug metabolism in the context of liver disease: Impact on pharmacokinetics and drug-drug interactions. Br J Clin Pharmacol 2023. [PMID: 38148609 DOI: 10.1111/bcp.15990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/07/2023] [Accepted: 12/13/2023] [Indexed: 12/28/2023] Open
Abstract
Changes in the pharmacokinetic and resulting pharmacodynamic properties of drugs are common in many chronic liver diseases, leading to adverse effects, drug interactions and increased risk of over- or underdosing of medications. Structural and functional hepatic impairment can have major effects on drug metabolism and transport. This review summarizes research on the functional changes in phase I and II metabolic enzymes and in transport proteins in patients with metabolic diseases such as type 2 diabetes, metabolic dysfunction-associated steatotic liver disease, metabolic dysfunction-associated steatohepatitis and cirrhosis, providing a clinical perspective on how these changes affect drug uptake and metabolism. Generally, a decrease in expression and/or activity of many enzymes of the cytochrome P450 family (e.g. CYP2E1 and CYP3A4), and of influx and efflux transporters (e.g. organic anion-transporting polypeptide [OATP]1B1, OATP2B1, OAT2 and bile salt export pump), has been recently documented in patients with liver disease. Decreased enzyme levels often correlate with increased severity of chronic liver disease. In subjects with hepatic impairment, there is potential for strong alterations of drug pharmacokinetics due to reduced absorption, increased volume of distribution, metabolism and extraction. Due to the altered pharmacokinetics, specific drug-drug interactions are also a potential issue to consider in patients with liver disease. Given the huge burden of liver disease in western societies, there is a need to improve awareness among all healthcare professionals and patients with liver disease to ensure appropriate drug prescriptions.
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Affiliation(s)
- Sara Armani
- CRS Clinical Research Services, Mannheim, Germany
| | - Andreas Geier
- Department of Internal Medicine and Hepatology, University Hospital, Würzburg, Germany
| | - Thomas Forst
- CRS Clinical Research Services, Mannheim, Germany
| | - Uta Merle
- Department of Internal Medicine IV, University Hospital, Heidelberg, Germany
| | - David H Alpers
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Tomlinson B, Li YH. What is the impact of type 2 diabetes mellitus on CYP450 metabolic activities? Expert Opin Drug Metab Toxicol 2023; 19:867-870. [PMID: 37997258 DOI: 10.1080/17425255.2023.2288246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/22/2023] [Indexed: 11/25/2023]
Affiliation(s)
- Brian Tomlinson
- Faculty of Medicine, Macau University of Science and Technology, Macau, China
| | - Yan-Hong Li
- The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
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Powell NR, Liang T, Ipe J, Cao S, Skaar TC, Desta Z, Qian HR, Ebert PJ, Chen Y, Thomas MK, Chalasani N. Clinically important alterations in pharmacogene expression in histologically severe nonalcoholic fatty liver disease. Nat Commun 2023; 14:1474. [PMID: 36927865 PMCID: PMC10020163 DOI: 10.1038/s41467-023-37209-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 03/07/2023] [Indexed: 03/18/2023] Open
Abstract
Polypharmacy is common in patients with nonalcoholic fatty liver disease (NAFLD) and previous reports suggest that NAFLD is associated with altered drug disposition. This study aims to determine if patients with NAFLD are at risk for altered drug response by characterizing changes in hepatic mRNA expression of genes mediating drug disposition (pharmacogenes) across the histological NAFLD severity spectrum. We utilize RNA-seq for 93 liver biopsies with histologically staged NAFLD Activity Score (NAS), fibrosis stage, and steatohepatitis (NASH). We identify 37 significant pharmacogene-NAFLD severity associations including CYP2C19 downregulation. We chose to validate CYP2C19 due to its actionability in drug prescribing. Meta-analysis of 16 independent studies demonstrate that CYP2C19 is significantly downregulated to 46% in NASH, to 58% in high NAS, and to 43% in severe fibrosis. Our data demonstrate the downregulation of CYP2C19 in NAFLD which supports developing personalized medicine approaches for drugs sensitive to metabolism by the CYP2C19 enzyme.
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Affiliation(s)
- Nicholas R Powell
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN, USA
| | - Tiebing Liang
- Indiana University School of Medicine, Department of Medicine, Division of Gastroenterology Hepatology, Indianapolis, IN, USA
| | - Joseph Ipe
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN, USA
| | - Sha Cao
- Indiana University School of Medicine, Department of Medicine, Division of Gastroenterology Hepatology, Indianapolis, IN, USA
| | - Todd C Skaar
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN, USA
| | - Zeruesenay Desta
- Indiana University School of Medicine, Department of Medicine, Division of Clinical Pharmacology, Indianapolis, IN, USA
| | | | | | - Yu Chen
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Naga Chalasani
- Indiana University School of Medicine, Department of Medicine, Division of Gastroenterology Hepatology, Indianapolis, IN, USA.
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