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Rohr BS, Krohmer E, Foerster KI, Burhenne J, Schulz M, Blank A, Mikus G, Haefeli WE. Time Course of the Interaction Between Oral Short-Term Ritonavir Therapy with Three Factor Xa Inhibitors and the Activity of CYP2D6, CYP2C19, and CYP3A4 in Healthy Volunteers. Clin Pharmacokinet 2024; 63:469-481. [PMID: 38393578 PMCID: PMC11052790 DOI: 10.1007/s40262-024-01350-x] [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] [Accepted: 01/29/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND We investigated the effect of a 5-day low-dose ritonavir therapy, as it is used in the treatment of COVID-19 with nirmatrelvir/ritonavir, on the pharmacokinetics of three factor Xa inhibitors (FXaI). Concurrently, the time course of the activities of the cytochromes P450 (CYP) 3A4, 2C19, and 2D6 was assessed. METHODS In an open-label, fixed sequence clinical trial, the effect and duration of a 5-day oral ritonavir (100 mg twice daily) treatment on the pharmacokinetics of three oral microdosed FXaI (rivaroxaban 25 µg, apixaban 25 µg, and edoxaban 50 µg) and microdosed probe drugs (midazolam 25 µg, yohimbine 50 µg, and omeprazole 100 µg) was evaluated in eight healthy volunteers. The plasma concentrations of all drugs were quantified using validated liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods and pharmacokinetics were analysed using non-compartmental analyses. RESULTS Ritonavir increased the exposure of apixaban, edoxaban, and rivaroxaban, but to a different extent the observed area under the plasma concentration-time curve (geometric mean ratio 1.29, 1.46, and 1.87, respectively). A strong CYP3A4 inhibition (geometric mean ratio > 10), a moderate CYP2C19 induction 2 days after ritonavir (0.64), and no alteration of CYP2D6 were observed. A CYP3A4 recovery half-life of 2.3 days was determined. CONCLUSION This trial with three microdosed FXaI suggests that at most the rivaroxaban dose should be reduced during short-term ritonavir, and only in patients receiving high maintenance doses. Thorough time series analyses demonstrated differential effects on three different drug-metabolising enzymes over time with immediate profound inhibition of CYP3A4 and only slow recovery after discontinuation. CLINICAL TRIAL REGISTRATION EudraCT number: 2021-006643-39.
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Affiliation(s)
- Brit S Rohr
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Evelyn Krohmer
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Martin Schulz
- Drug Commission of German Pharmacists and Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Medical Faculty of Heidelberg, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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Hindley B, Lip GYH, McCloskey AP, Penson PE. Pharmacokinetics and pharmacodynamics of direct oral anticoagulants. Expert Opin Drug Metab Toxicol 2023; 19:911-923. [PMID: 37991392 DOI: 10.1080/17425255.2023.2287472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 11/21/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) have overtaken vitamin K antagonists to become the most widely used method of anticoagulation for most indications. Their stable and predictable pharmacokinetics combined with relatively simple dosing, and the absence of routine monitoring has made them an attractive proposition for healthcare providers. Despite the benefits of DOACs as a class, important differences exist between individual DOAC drugs in respect of their pharmacokinetic and pharmacodynamic profiles with implications for dosing and reversal in cases of major bleeding. AREAS COVERED This review summarizes the state of knowledge relating to the pharmacokinetics of dabigatran (factor IIa/thrombin inhibitor) and apixaban, edoxaban and rivaroxaban (factor Xa) inhibitors. We focus on pharmacokinetic differences between the drugs which may have clinically significant implications. EXPERT OPINION Patient-centered care necessitates a careful consideration of the pharmacokinetic and pharmacodynamic differences between DOACs, and how these relate to individual patient circumstances. Prescribers should be aware of the potential for pharmacokinetic drug interactions with DOACs which may influence prescribing decisions in patients with multiple comorbidities. In order to give an appropriate dose of DOAC drugs, accurate estimation of renal function using the Cockcroft-Gault formula using actual body weight is necessary. An increasing body of evidence supports the use of DOACs in patients who are obese, and this is becoming more routine in clinical practice.
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Affiliation(s)
- B Hindley
- Pharmacy Department, Aintree University Hospital, Liverpool, UK
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - G Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - A P McCloskey
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - P E Penson
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
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Bosch F, Mulder F, Franken L, Willemsen A, Rentinck M, van den Berg P, Bakker SLD, van der Velden A, van Es N, Mathôt R, Kamphuisen PW. Effect of the P-glycoprotein inhibitor tamoxifen on edoxaban plasma levels in women with breast cancer. Thromb Res 2023; 228:46-53. [PMID: 37269716 DOI: 10.1016/j.thromres.2023.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/10/2023] [Accepted: 05/24/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Concomitant use of P-glycoprotein inhibitors can reduce clearance of edoxaban and increase its plasma concentration. Caution is advised with simultaneous use of edoxaban and the frequently used P-glycoprotein inhibitor tamoxifen. However, pharmacokinetic data are lacking. OBJECTIVES This study aimed to assess the effect of tamoxifen on edoxaban clearance. METHODS This was a prospective, self-controlled, pharmacokinetic study in breast cancer participants starting tamoxifen. Edoxaban was given at a dose of 60 mg once daily for 4 consecutive days, first without tamoxifen and later with concomitant tamoxifen in steady-state. On day 4 of both edoxaban sequences, serial blood samples were taken. A population pharmacokinetic model was developed using nonlinear mixed effects modelling in which the effect of tamoxifen on edoxaban clearance was assessed. Additionally, mean area under the curves (AUC) were estimated. Geometric least square means (GLM) ratios were calculated and no interaction was concluded if the 90 % CI was within the 80-125 % no-effect boundaries. RESULTS Twenty-four women with breast cancer scheduled for tamoxifen were included. The median age was 56 years (IQR 51-63). The average edoxaban clearance was 32.0 L/h (95 % CI, 11.1-35.0 L/h). There was no effect of tamoxifen on edoxaban clearance, with a fraction of 100 % (95 % CI 92-108) compared to clearance without tamoxifen. The mean AUCs were 1923 ng*h/ml (SD 695) without tamoxifen and 1947 ng*h/ml (SD 595) with tamoxifen (GLM-ratio 100.4; 90 % CI 98.6-102.2). CONCLUSIONS Concomitant use of the P-glycoprotein inhibitor tamoxifen does not lead to reduced clearance of edoxaban in patients with breast cancer.
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Affiliation(s)
- Floris Bosch
- Department of Internal Medicine, Tergooi Medical Center, Hilversum, the Netherlands; Amsterdam UMC location University of Amsterdam, Department of Vascular Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands.
| | - Frits Mulder
- Department of Internal Medicine, Tergooi Medical Center, Hilversum, the Netherlands; Amsterdam UMC location University of Amsterdam, Department of Vascular Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands
| | - Linda Franken
- Department of Hospital Pharmacy - Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Annelieke Willemsen
- Department of Internal Medicine, Tergooi Medical Center, Hilversum, the Netherlands
| | - Marjolein Rentinck
- Department of Internal Medicine, Tergooi Medical Center, Hilversum, the Netherlands
| | - Pieter van den Berg
- Department of Internal Medicine, Tergooi Medical Center, Hilversum, the Netherlands
| | | | - Ankie van der Velden
- Department of Internal Medicine, Tergooi Medical Center, Hilversum, the Netherlands
| | - Nick van Es
- Amsterdam UMC location University of Amsterdam, Department of Vascular Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands
| | - Ron Mathôt
- Department of Hospital Pharmacy - Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Pieter W Kamphuisen
- Department of Internal Medicine, Tergooi Medical Center, Hilversum, the Netherlands; Amsterdam UMC location University of Amsterdam, Department of Vascular Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands
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Xu R, Liu W, Ge W, He H, Jiang Q. Physiologically-based pharmacokinetic pharmacodynamic parent-metabolite model of edoxaban to predict drug-drug-disease interactions: M4 contribution. CPT Pharmacometrics Syst Pharmacol 2023; 12:1093-1106. [PMID: 37101392 PMCID: PMC10431043 DOI: 10.1002/psp4.12977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/13/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023] Open
Abstract
This study aimed to develop a physiologically-based pharmacokinetic pharmacodynamic (PBPK/PD) parent-metabolite model of edoxaban, an oral anticoagulant with a narrow therapeutic index, and to predict pharmacokinetic (PK)/PD profiles and potential drug-drug-disease interactions (DDDIs) in patients with renal impairment. A whole-body PBPK model with a linear additive PD model of edoxaban and its active metabolite M4 was developed and validated in SimCYP for healthy adults with or without interacting drugs. The model was extrapolated to situations including renal impairment and drug-drug interactions (DDIs). Observed PK and PD data in adults were compared with predicted data. The effect of several model parameters on the PK/PD response of edoxaban and M4 was investigated in sensitivity analysis. The PBPK/PD model successfully predicted PK profiles of edoxaban and M4 as well as anticoagulation PD responses with or without the influence of interacting drugs. For patients with renal impairment, the PBPK model successfully predicted the fold change in each impairment group. Inhibitory DDI and renal impairment had a synergistic effect on the increased exposure of edoxaban and M4, and their downstream anticoagulation PD effect. Sensitivity analysis and DDDI simulation show that renal clearance, intestinal P-glycoprotein activity, and hepatic OATP1B1 activity are the major factors affecting edoxaban-M4 PK profiles and PD responses. Anticoagulation effect induced by M4 cannot be ignored when OATP1B1 is inhibited or downregulated. Our study provides a reasonable approach to adjust the dose of edoxaban in several complicated scenarios especially when M4 cannot be ignored due to decreased OATP1B1 activity.
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Affiliation(s)
- Ruijuan Xu
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Wenyuan Liu
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
- Department of PharmacyNanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese MedicineNanjingChina
| | - Weihong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
- Department of PharmacyNanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese MedicineNanjingChina
| | - Hua He
- Center of Drug Metabolism and PharmacokineticsChina Pharmaceutical UniversityNanjingChina
| | - Qing Jiang
- Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
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Lenard A, Hermann SA, Stoll F, Burhenne J, Foerster KI, Mikus G, Meid AD, Haefeli WE, Blank A. Effect of Clarithromycin, a Strong CYP3A and P-glycoprotein Inhibitor, on the Pharmacokinetics of Edoxaban in Healthy Volunteers and the Evaluation of the Drug Interaction with Other Oral Factor Xa Inhibitors by a Microdose Cocktail Approach. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07443-2. [PMID: 36870039 DOI: 10.1007/s10557-023-07443-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 03/05/2023]
Abstract
PURPOSE We assessed the differential effect of clarithromycin, a strong inhibitor of cytochrome P450 (CYP) 3A4 and P-glycoprotein, on the pharmacokinetics of a regular dose of edoxaban and on a microdose cocktail of factor Xa inhibitors (FXaI). Concurrently, CYP3A activity was determined with a midazolam microdose. METHODS In an open-label fixed-sequence trial in 12 healthy volunteers, the pharmacokinetics of a microdosed FXaI cocktail (μ-FXaI; 25 μg apixaban, 50 μg edoxaban, and 25 μg rivaroxaban) and of 60 mg edoxaban before and during clarithromycin (2 x 500 mg/d) dosed to steady-state was evaluated. Plasma concentrations of study drugs were quantified using validated ultra-performance liquid chromatography-tandem mass spectrometry methods. RESULTS Therapeutic clarithromycin doses increased the exposure of a therapeutic 60 mg dose of edoxaban with a geometric mean ratio (GMR) of the area under the plasma concentration-time curve (AUC) of 1.53 (90 % CI: 1.37-1.70; p < 0.0001). Clarithromycin also increased the GMR (90% CI) of the exposure of microdosed FXaI apixaban to 1.38 (1.26-1.51), edoxaban to 2.03 (1.84-2.24), and rivaroxaban to 1.44 (1.27-1.63). AUC changes observed for the therapeutic edoxaban dose were significantly smaller than those observed with the microdose (p < 0.001). CONCLUSION Clarithromycin increases FXaI exposure. However, the magnitude of this drug interaction is not expected to be clinically relevant. The edoxaban microdose overestimates the extent of the drug interaction with the therapeutic dose, whereas AUC ratios for apixaban and rivaroxaban were comparable to the interaction with therapeutic doses as reported in the literature. TRIAL REGISTRATION EudraCT Number: 2018-002490-22.
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Affiliation(s)
- Alexander Lenard
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Simon A Hermann
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Felicitas Stoll
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Juergen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany.
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Prediction and Implications of Edoxaban-Associated Bleeding in Patients after Critical Illness. J Clin Med 2023; 12:jcm12030860. [PMID: 36769508 PMCID: PMC9918203 DOI: 10.3390/jcm12030860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/28/2022] [Accepted: 01/20/2023] [Indexed: 01/24/2023] Open
Abstract
In this retrospective study, we aimed to identify the risk factors for bleeding in patients after critical illness during edoxaban treatment. Data from patients who received edoxaban after critical illness at the Emergency Department at a tertiary care hospital were obtained from the hospital medical records. Multivariate analysis revealed the risk factors for edoxaban-associated bleeding. Additionally, we developed an edoxaban-associated bleeding score (EAB score) based on these results. The derived EAB score was compared with the HAS-BLED score using receiver operating characteristic (ROC) curve analysis. Bleeding was observed in 42 of 114 patients (36.8%). We identified the following bleeding predictors (odds ratios, 95% confidence interval, score points) using multivariate analysis: concomitant use of antiplatelet agents (6.759, 2.047-22.32, 2 points), concomitant use of P-glycoprotein inhibitors (3.825, 1.484-9.856, 1 point), prothrombin time (PT)% following edoxaban administration of <75% and ≥60% (2.507, 0.788-7.970, 1 point), and PT% following edoxaban administration of <60% (11.23, 3.560-35.42, 3 points). The ROC curve analysis revealed an area under the curve of 0.826 for the EAB score and 0.625 for the HAS-BLED score. Under appropriate edoxaban dosing regimens in patients after critical illness, a combination of antiplatelet agents, P-gp inhibitors, and a low PT% following edoxaban administration were identified as strong risk factors for bleeding.
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Wen HN, He QF, Xiang XQ, Jiao Z, Yu JG. Predicting drug-drug interactions with physiologically based pharmacokinetic/pharmacodynamic modelling and optimal dosing of apixaban and rivaroxaban with dronedarone co-administration. Thromb Res 2022; 218:24-34. [PMID: 35985100 DOI: 10.1016/j.thromres.2022.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND The concurrent administration of dronedarone and oral anti-coagulants is common because both are used in managing atrial fibrillation (AF). Dronedarone is a moderate inhibitor of the cytochrome P450 3A4 (CYP3A4) enzyme and P-glycoprotein (P-gp). Apixaban and rivaroxaban are P-gp and CYP3A4 substrates. This study aims to investigate the impact of exposure and bleeding risk of apixaban or rivaroxaban when co-administered with dronedarone using physiologically based pharmacokinetic/pharmacodynamic analysis. METHODS Modeling and simulation were conducted using Simcyp® Simulator. The parameters required for dronedarone modeling were collected from the literature. The developed dronedarone physiologically based pharmacokinetic (PBPK) model was verified using reported drug-drug interactions (DDIs) between dronedarone and CYP3A4 and P-gp substrates. The model was applied to evaluate the DDI potential of dronedarone on the exposure of apixaban 5 mg every 12 h or rivaroxaban 20 mg every 24 h in geriatric and renally impaired populations. DDIs precipitating major bleeding risks were assessed using exposure-response analyses derived from literature. RESULTS The model accurately described the pharmacokinetics of orally administered dronedarone in healthy subjects and accurately predicted DDIs between dronedarone and four CYP3A4 and P-gp substrates with fold errors <1.5. Dronedarone co-administration led to a 1.29 (90 % confidence interval (CI): 1.14-1.50) to 1.31 (90 % CI: 1.12-1.46)-fold increase in the area under concentration-time curve for rivaroxaban and 1.33 (90 % CI: 1.15-1.68) to 1.46 (90 % CI: 1.24-1.92)-fold increase for apixaban. The PD model indicated that dronedarone co-administration might potentiate the mean major bleeding risk of apixaban with a 1.45 to 1.95-fold increase. However, the mean major bleeding risk of rivaroxaban was increased by <1.5-fold in patients with normal or impaired renal function. CONCLUSIONS Dronedarone co-administration increased the exposure of rivaroxaban and apixaban and might potentiate major bleeding risks. Reduced apixaban and rivaroxaban dosing regimens are recommended when dronedarone is co-administered to patients with AF.
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Affiliation(s)
- Hai-Ni Wen
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, PR China
| | - Qing-Feng He
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai, PR China
| | - Xiao-Qiang Xiang
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai, PR China.
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, PR China.
| | - Jian-Guang Yu
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, PR China.
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Gritsch D, Gonzalez Castro LN. Relevant pharmacologic interactions in the concurrent management of brain tumor-related epilepsy and venous thromboembolism: a systematic review. J Neurooncol 2022; 157:285-296. [PMID: 35312937 DOI: 10.1007/s11060-022-03984-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/05/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Co-administration of direct oral anticoagulants (DOACs) with antiepileptic drugs (AEDs) is increasingly common in brain tumor patients. We therefore performed a systematic review of the current evidence for potential drug interactions between DOACs and AEDs in this patient population. METHODS We conducted a systematic review of the literature via PubMed according to PRISMA guidelines (last accessed December 15, 2021). Included were clinical studies and case reports, written in English language and published between 2010 and 2021, that investigated concurrent clinical use of AEDs with DOACs for any indication. Non-English articles, articles not related to our research question, review articles and commentaries were excluded. Full-text articles were evaluated for possible confounding factors and results were summarized using a data table highlighting the key characteristics of each article. RESULTS We identified a total of 122 unique articles, of which 27 were deemed relevant to our research question. Of these, 8 articles were clinical studies (n = 295,415 patients) and 19 were case reports (n = 25 patients). Only 3 clinical studies and 2 case reports reported interactions between AEDs and DOACs in patients with active cancer and none reported interactions in patients with brain tumors. CONCLUSION We have identified low (class IV) level evidence of potential drug interactions between DOACs and AEDs. Even though there is no current report of interactions in brain tumor patients, neuro-oncology providers should be aware of the emerging evidence regarding drug interactions between DOACs and AEDs and take this into consideration when concurrently prescribing these to patients.
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Affiliation(s)
- David Gritsch
- Mayo Clinic Scottsdale: Mayo Clinic Arizona, Phoenix, AZ, USA.
| | - L Nicolas Gonzalez Castro
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
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9
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Husain A, Makadia V, Valicherla GR, Riyazuddin M, Gayen JR. Approaches to minimize the effects of P-glycoprotein in drug transport: A review. Drug Dev Res 2022; 83:825-841. [PMID: 35103340 DOI: 10.1002/ddr.21918] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/21/2021] [Accepted: 01/13/2022] [Indexed: 12/20/2022]
Abstract
P-glycoprotein (P-gp) is a transporter protein that is come under the ATP binding cassette family of proteins. It is situated on the surface of the intestine epithelium, where P-gp substrate binds to the transporter and is pumped into the intestine lumen by the ATP-driven energy-dependent process. In this review, we summarize the role of the P-gp efflux transporter situated on the intestine, the clinical importance of P-gp related drug interactions, and approaches to minimize the effect of P-gp in drug transport. This review also focuses on the impact of P-gp on the bioavailability of the orally administered drug. Many drug's oral bioavailabilities can improve by concomitant use of P-gp inhibitors. Multidrug resistance are reduced by using some naturally occurring compounds obtained from plants and several synthetic P-gp inhibitors. Formulation strategies, one of the most important approaches to mimic the P-gp transporter's action, finally enhancing the oral bioavailability of the drug by inhibiting its P-gp efflux. Vitamin E TPGS, Gelucire 44/14 and other pharmaceutical/formulation excipients inhibit the P-gp efflux. A prodrug approach might be a useful strategy to overcome drug resistance. Prodrug helps to enhance the solubility or alter the pharmacokinetic properties but does not diminish the pharmacological action.
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Affiliation(s)
- Athar Husain
- Pharmaceutics & Pharmacokinetics Division, CSIR-Central Drug Research Institute, Lucknow, 226031, India.,Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India
| | - Vishal Makadia
- Pharmaceutics & Pharmacokinetics Division, CSIR-Central Drug Research Institute, Lucknow, 226031, India.,Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research, Raibarelly, India
| | - Guru R Valicherla
- Pharmaceutics & Pharmacokinetics Division, CSIR-Central Drug Research Institute, Lucknow, 226031, India.,Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India
| | - Mohammed Riyazuddin
- Pharmaceutics & Pharmacokinetics Division, CSIR-Central Drug Research Institute, Lucknow, 226031, India
| | - Jiaur R Gayen
- Pharmaceutics & Pharmacokinetics Division, CSIR-Central Drug Research Institute, Lucknow, 226031, India.,Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, 201002, India
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10
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Rohr BS, Foerster KI, Blank A, Burhenne J, Mahmoudi M, Haefeli WE, Mikus G. Perpetrator Characteristics of Azole Antifungal Drugs on Three Oral Factor Xa Inhibitors Administered as a Microdosed Cocktail. Clin Pharmacokinet 2021; 61:97-109. [PMID: 34273071 PMCID: PMC8761715 DOI: 10.1007/s40262-021-01051-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 02/05/2023]
Abstract
Background Factor Xa inhibitors (FXaIs) are increasingly used without having sufficient drug–drug interaction data. Using a microdosed cocktail methodology could support filling the knowledge gap quickly. Methods In a randomised crossover trial, we investigated the drug–drug interactions between six oral azole antifungals and a microdosed FXaI cocktail containing 25 µg rivaroxaban, 25 µg apixaban, and 50 µg edoxaban. Additionally, different enzyme activities were also monitored using a microdosed cocktail approach. The six different azole antifungals were administered in therapeutic doses over a 24 h period, while the microdosed cocktails were administered 1 h after administration of the azole antifungals. Results Ketoconazole and posaconazole were the strongest perpetrators, showing similar increases as apixaban (area under the concentration–time curve ratio [AUCR] 1.64 and 1.62, respectively) and edoxaban (AUCR 2.08 and 2.1, respectively), whereas ketoconazole increased rivaroxaban 2.32-fold but only increased posaconazole 1.37-fold. All other azole antifungals showed less perpetrator effects on the FXaIs. Cytochrome P450 (CYP) 3A inhibition was confirmed using microdosed midazolam, with ketoconazole also the most potent perpetrator (8.42-fold). Conclusion Drug–drug interactions for three victim drugs of the same drug class (FXaIs) with different clearance mechanisms can be studied using a microdosed cocktail approach. Using members of the azole antifungal drug class as perpetrators, multiple interactions can be studied in one trial, and a more detailed insight into the underlying interaction mechanisms is possible. Clinical Trial Registration EudraCT number: 2017-004453-16. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01051-9.
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Affiliation(s)
- Brit Silja Rohr
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Kathrin Isabelle Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Mazyar Mahmoudi
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Walter Emil Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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11
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Hong Y, Ishizuka T, Watanabe A, Tachibana M, Lee M, Ishizuka H, LaCreta F, Abutarif M. Model-based assessments of CYP3A-mediated drug-drug interaction risk of milademetan. Clin Transl Sci 2021; 14:2220-2230. [PMID: 34080309 PMCID: PMC8604211 DOI: 10.1111/cts.13082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 11/30/2022] Open
Abstract
Milademetan is a small‐molecule inhibitor of murine double minute 2 (MDM2) that is in clinical development for advanced solid tumors and hematological cancers, including liposarcoma and acute myeloid leukemia. Milademetan is a CYP3A and P‐glycoprotein substrate and moderate CYP3A inhibitor. The current study aims to understand the drug‐drug interaction (DDI) risk of milademetan as a CYP3A substrate during its early clinical development. A clinical DDI study of milademetan (NCT03614455) showed that concomitant administration of single‐dose milademetan with the strong CYP3A inhibitor itraconazole or posaconazole increased milademetan mean area under the curve from zero to infinity (AUCinf) by 2.15‐fold (90% confidence interval [CI], 1.98–2.34) and 2.49‐fold (90% CI, 2.26–2.74), respectively, supporting that the milademetan dose should be reduced by 50% when concomitantly administered with strong CYP3A inhibitors. A physiologically‐based pharmacokinetic (PBPK) model of milademetan was subsequently developed to predict the magnitude of CYP3A‐mediated DDI potential of milademetan with moderate CYP3A inhibitors. The PBPK model predicted an increase in milademetan exposure of 1.72‐fold (90% CI, 1.69–1.76) with fluconazole, 1.91‐fold (90% CI, 1.83–1.99) with erythromycin, and 2.02‐fold (90% CI, 1.93–2.11) with verapamil. In addition, it estimated that milademetan’s original dose (160 mg once daily) could be resumed from its half‐reduced dose 3 days after discontinuation of concomitant strong CYP3A inhibitors. The established PBPK model of milademetan was qualified and considered to be robust enough to support continued development of milademetan.
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Affiliation(s)
- Ying Hong
- Quantitative Clinical Pharmacology, Daiichi Sankyo, Inc, Basking Ridge, New Jersey, USA
| | - Tomoko Ishizuka
- Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Akiko Watanabe
- Quantitative Clinical Pharmacology, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Masaya Tachibana
- Quantitative Clinical Pharmacology, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Mark Lee
- Quantitative Clinical Pharmacology, Daiichi Sankyo, Inc, Basking Ridge, New Jersey, USA
| | - Hitoshi Ishizuka
- Quantitative Clinical Pharmacology, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Frank LaCreta
- Quantitative Clinical Pharmacology, Daiichi Sankyo, Inc, Basking Ridge, New Jersey, USA
| | - Malaz Abutarif
- Quantitative Clinical Pharmacology, Daiichi Sankyo, Inc, Basking Ridge, New Jersey, USA
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12
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Corsini A, Ferri N, Proietti M, Boriani G. Edoxaban and the Issue of Drug-Drug Interactions: From Pharmacology to Clinical Practice. Drugs 2021; 80:1065-1083. [PMID: 32504376 DOI: 10.1007/s40265-020-01328-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Edoxaban, a direct factor Xa inhibitor, is the latest of the non-vitamin K antagonist oral anticoagulants (NOACs). Despite being marketed later than other NOACs, its use is now spreading in current clinical practice, being indicated for both thromboprophylaxis in patients with non-valvular atrial fibrillation (NVAF) and for the treatment and prevention of venous thromboembolism (VTE). In patients with multiple conditions, the contemporary administration of several drugs can cause relevant drug-drug interactions (DDIs), which can affect drugs' pharmacokinetics and pharmacodynamics. Usually, all the NOACs are considered to have significantly fewer DDIs than vitamin K antagonists; notwithstanding, this is actually not true, all of them are affected by DDIs with drugs that can influence the activity (induction or inhibition) of P-glycoprotein (P-gp) and cytochrome P450 3A4, both responsible for the disposition and metabolism of NOACs to a different extent. In this review/expert opinion, we focused on an extensive report of edoxaban DDIs. All the relevant drugs categories have been examined to report on significant DDIs, discussing the impact on edoxaban pharmacokinetics and pharmacodynamics, and the evidence for dose adjustment. Our analysis found that, despite a restrained number of interactions, some strong inhibitors/inducers of P-gp and drug-metabolising enzymes can affect edoxaban concentration, just as it happens with other NOACs, implying the need for a dose adjustment. However, our analysis of edoxaban DDIs suggests that given the small propensity for interactions of this agent, its use represents an acceptable clinical decision. Still, DDIs can be significant in certain clinical situations and a careful evaluation is always needed when prescribing NOACs.
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Affiliation(s)
- Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy.,Multimedica IRCCS, Milan, Italy
| | - Nicola Ferri
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Padua, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Via della Commenda 19, 20122, Milan, Italy. .,Geriatric Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy. .,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
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13
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Shnayder NA, Petrova MM, Shesternya PA, Savinova AV, Bochanova EN, Zimnitskaya OV, Pozhilenkova EA, Nasyrova RF. Using Pharmacogenetics of Direct Oral Anticoagulants to Predict Changes in Their Pharmacokinetics and the Risk of Adverse Drug Reactions. Biomedicines 2021; 9:biomedicines9050451. [PMID: 33922084 PMCID: PMC8143539 DOI: 10.3390/biomedicines9050451] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 12/13/2022] Open
Abstract
Dabigatran, rivaroxaban, apixaban, and edoxaban are direct oral anticoagulants (DOACs) that are increasingly used worldwide. Taking into account their widespread use for the prevention of thromboembolism in cardiology, neurology, orthopedics, and coronavirus disease 2019 (COVID 19) as well as their different pharmacokinetics and pharmacogenetics dependence, it is critical to explore new opportunities for DOACs administration and predict their dosage when used as monotherapy or in combination with other drugs. In this review, we describe the details of the relative pharmacogenetics on the pharmacokinetics of DOACs as well as new data concerning the clinical characteristics that predetermine the needed dosage and the risk of adverse drug reactions (ADRs). The usefulness of genetic information before and shortly after the initiation of DOACs is also discussed. The reasons for particular attention to these issues are not only new genetic knowledge and genotyping possibilities, but also the risk of serious ADRs (primarily, gastrointestinal bleeding). Taking into account the effect of the carriership of single nucleotide variants (SNVs) of genes encoding biotransformation enzymes and DOACs metabolism, the use of these measures is important to predict changes in pharmacokinetics and the risk of ADRs in patients with a high risk of thromboembolism who receive anticoagulant therapy.
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Affiliation(s)
- Natalia A. Shnayder
- The Centre of Personalized Psychiatry and Neurology, V. M. Bekhterev National Medical Research Center for Psychiatry and Neurology (V.M. Bekhterev NMRC PN) 3, Bekhterev Str., 192019 Saint-Petersburg, Russia;
- The CoreFacilities Molecular and Cell Technologies, V. F. Voino-Yasenetsky Krasnoyarsk State Medical University (V.F. Voino-YasenetskyKrasSMU) 1, PartizanZheleznyak Str., 660022 Krasnoyarsk, Russia; (M.M.P.); (P.A.S.); (E.N.B.); (O.V.Z.); (E.A.P.)
- Correspondence: (N.A.S.); (R.F.N.); Tel.: +7-(812)-670-02-20 (N.A.S. & R.F.N.)
| | - Marina M. Petrova
- The CoreFacilities Molecular and Cell Technologies, V. F. Voino-Yasenetsky Krasnoyarsk State Medical University (V.F. Voino-YasenetskyKrasSMU) 1, PartizanZheleznyak Str., 660022 Krasnoyarsk, Russia; (M.M.P.); (P.A.S.); (E.N.B.); (O.V.Z.); (E.A.P.)
| | - Pavel A. Shesternya
- The CoreFacilities Molecular and Cell Technologies, V. F. Voino-Yasenetsky Krasnoyarsk State Medical University (V.F. Voino-YasenetskyKrasSMU) 1, PartizanZheleznyak Str., 660022 Krasnoyarsk, Russia; (M.M.P.); (P.A.S.); (E.N.B.); (O.V.Z.); (E.A.P.)
| | - Alina V. Savinova
- The Centre of Personalized Psychiatry and Neurology, V. M. Bekhterev National Medical Research Center for Psychiatry and Neurology (V.M. Bekhterev NMRC PN) 3, Bekhterev Str., 192019 Saint-Petersburg, Russia;
| | - Elena N. Bochanova
- The CoreFacilities Molecular and Cell Technologies, V. F. Voino-Yasenetsky Krasnoyarsk State Medical University (V.F. Voino-YasenetskyKrasSMU) 1, PartizanZheleznyak Str., 660022 Krasnoyarsk, Russia; (M.M.P.); (P.A.S.); (E.N.B.); (O.V.Z.); (E.A.P.)
| | - Olga V. Zimnitskaya
- The CoreFacilities Molecular and Cell Technologies, V. F. Voino-Yasenetsky Krasnoyarsk State Medical University (V.F. Voino-YasenetskyKrasSMU) 1, PartizanZheleznyak Str., 660022 Krasnoyarsk, Russia; (M.M.P.); (P.A.S.); (E.N.B.); (O.V.Z.); (E.A.P.)
| | - Elena A. Pozhilenkova
- The CoreFacilities Molecular and Cell Technologies, V. F. Voino-Yasenetsky Krasnoyarsk State Medical University (V.F. Voino-YasenetskyKrasSMU) 1, PartizanZheleznyak Str., 660022 Krasnoyarsk, Russia; (M.M.P.); (P.A.S.); (E.N.B.); (O.V.Z.); (E.A.P.)
| | - Regina F. Nasyrova
- The CoreFacilities Molecular and Cell Technologies, V. F. Voino-Yasenetsky Krasnoyarsk State Medical University (V.F. Voino-YasenetskyKrasSMU) 1, PartizanZheleznyak Str., 660022 Krasnoyarsk, Russia; (M.M.P.); (P.A.S.); (E.N.B.); (O.V.Z.); (E.A.P.)
- Correspondence: (N.A.S.); (R.F.N.); Tel.: +7-(812)-670-02-20 (N.A.S. & R.F.N.)
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14
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Dunois C. Laboratory Monitoring of Direct Oral Anticoagulants (DOACs). Biomedicines 2021; 9:biomedicines9050445. [PMID: 33919121 PMCID: PMC8143174 DOI: 10.3390/biomedicines9050445] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022] Open
Abstract
The introduction of direct oral anticoagulants (DOACs), such as dabigatran, rivaroxaban, apixaban, edoxaban, and betrixaban, provides safe and effective alternative to previous anticoagulant therapies. DOACs directly, selectively, and reversibly inhibit factors IIa or Xa. The coagulation effect follows the plasma concentration-time profile of the respective anticoagulant. The short half-life of a DOAC constrains the daily oral intake. Because DOACs have predictable pharmacokinetic and pharmacodynamic responses at a fixed dose, they do not require monitoring. However in specific clinical situations and for particular patient populations, testing may be helpful for patient management. The effect of DOACs on the screening coagulation assays such as prothrombin time (PT), activated partial thromboplastin time (APTT), and thrombin time (TT) is directly linked to reagent composition, and clotting time can be different from reagent to reagent, depending on the DOAC's reagent sensitivity. Liquid chromatography-mass spectrometry (LC-MS/MS) is considered the gold standard method for DOAC measurement, but it is time consuming and requires expensive equipment. The general consensus for the assessment of a DOAC is clotting or chromogenic assays using specific standard calibrators and controls. This review provides a short summary of DOAC properties and an update on laboratory methods for measuring DOACs.
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Affiliation(s)
- Claire Dunois
- HYPHEN BioMed, Sysmex Group, 95000 Neuville sur Oise, France
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15
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Kato T, Mikkaichi T, Yoshigae Y, Okudaira N, Shimizu T, Izumi T, Ando S, Matsumoto Y. Quantitative analysis of an impact of P-glycoprotein on edoxaban's disposition using a human physiologically based pharmacokinetic (PBPK) model. Int J Pharm 2021; 597:120349. [PMID: 33545293 DOI: 10.1016/j.ijpharm.2021.120349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/31/2020] [Accepted: 01/31/2021] [Indexed: 12/18/2022]
Abstract
The purpose of this study was to evaluate the impact of P-glycoprotein (P-gp) efflux on edoxaban absorption in gastrointestinal tracts quantitatively by a physiologically based pharmacokinetic (PBPK) model constructed with clinical and non-clinical observations (using GastroPlus™ software). An absorption process was described by the advanced compartmental absorption and transit model with the P-gp function. A human PBPK model was constructed by integrating the clinical and non-clinical observations. The constructed model was demonstrated to reproduce the data observed in the mass-balance study. Thus, elimination pathways can be quantitatively incorporated into the model. A constructed model successfully described the difference in slopes of plasma concentration (Cp)-time curve at around 8 - 24 hr post-dose between intravenous infusion and oral administration. Furthermore, the model without P-gp efflux activity can reproduce the Cp-time profile in the absence of P-gp activity observed from the clinical DDI study results. Since the difference of slopes between intravenous infusion and oral administration also disappeared by the absence of P-gp efflux activity, P-gp must be a key molecule to govern edoxaban's PK behavior. The constructed PBPK model will help us to understand the significant contribution of P-gp in edoxaban's disposition in gastrointestinal tracts quantitatively.
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Affiliation(s)
- Takafumi Kato
- Formulation Technology Research Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan.
| | - Tsuyoshi Mikkaichi
- Drug Metabolism & Pharmacokinetics Research Laboratories,Daiichi Sankyo Co., Ltd., Tokyo, Japan.
| | - Yasushi Yoshigae
- Drug Metabolism & Pharmacokinetics Research Laboratories,Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Noriko Okudaira
- Drug Metabolism & Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd. (Simcyp Division Certara, Inc., Tokyo, Japan), Tokyo, Japan
| | - Takako Shimizu
- Quantitative Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Takashi Izumi
- Drug Metabolism & Pharmacokinetics Research Laboratories,Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Shuichi Ando
- Formulation Technology Research Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Yoshiaki Matsumoto
- Laboratory of Clinical Pharmacokinetics, School of Pharmacy, Nihon University, Chiba, Japan
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16
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Havrdová M, Saari TI, Jalonen J, Peltoniemi M, Kurkela M, Vahlberg T, Tienhaara A, Backman JT, Olkkola KT, Schramko A. Relationship of Edoxaban Plasma Concentration and Blood Coagulation in Healthy Volunteers Using Standard Laboratory Tests and Viscoelastic Analysis. J Clin Pharmacol 2020; 61:522-530. [PMID: 33027547 DOI: 10.1002/jcph.1758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 09/16/2020] [Indexed: 11/09/2022]
Abstract
The capability of viscoelastic measurement parameters to screen anticoagulation activity of edoxaban in relation to its plasma concentrations was evaluated in 15 healthy male volunteers. Blood samples were drawn before the oral administration of edoxaban 60 mg and 2, 4, 6, 8, and 24 hours after administration. At each time, standard coagulation tests were performed, blood viscoelastic properties were measured with a thromboelastometry device ROTEM delta analyzer (Instrumentation Laboratory, Werfen, Barcelona, Spain), and edoxaban plasma concentrations were measured. Our primary interest was the possible correlation between edoxaban plasma concentrations and values for ROTEM ExTEM, and FibTEM. We also studied the correlation of edoxaban plasma concentrations with the results of standard coagulation tests. We saw the effect of a single dose of edoxaban most clearly in clotting time (CT) of ROTEM ExTEM and FibTEM. Changes in these parameters correlated significantly with edoxaban plasma concentrations up to 6 hours from the ingestion of the drug. Activated partial thromboplastin time, prothrombin time, and anti-factor Xa were also affected. Peak changes were observed 2 and 4 hours after administration of edoxaban. The changes were mostly reversed after 8 hours. In conclusion, ROTEM CT correlates significantly with edoxaban plasma concentrations and can be used to estimate the effect of edoxaban. ROTEM should be considered as part of the assessment of coagulation, with the big advantage of being readily available on site.
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Affiliation(s)
- Martina Havrdová
- Emergency Medical Services, Hospital District of Southwest Finland, Turku, Finland.,Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland
| | - Teijo I Saari
- Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Jouko Jalonen
- Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Marko Peltoniemi
- Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Mika Kurkela
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, and the Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tero Vahlberg
- Department of Clinical Medicine, Biostatistics, University of Turku, Turku, Finland
| | - Anri Tienhaara
- Hematology Laboratory, Tykslab, Turku University Hospital, Turku, Finland
| | - Janne T Backman
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, and the Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Klaus T Olkkola
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Alexey Schramko
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
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17
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Microdosed Cocktail of Three Oral Factor Xa Inhibitors to Evaluate Drug-Drug Interactions with Potential Perpetrator Drugs. Clin Pharmacokinet 2020; 58:1155-1163. [PMID: 30828771 DOI: 10.1007/s40262-019-00749-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to prove the suitability of simultaneously administered microdoses of the factor Xa inhibitors (FXaIs) rivaroxaban, apixaban and edoxaban (100 µg in total). To evaluate drug-drug interactions, the impact of ketoconazole, a known strong inhibitor of cytochrome P450 3A4 and P-glycoprotein, was studied. METHODS In a crossover clinical trial, 18 healthy volunteers were randomized to the two treatments using microdoses of rivaroxaban, apixaban and edoxaban alone and when coadministered with ketoconazole. Plasma and urine concentrations of microdosed apixaban, edoxaban and rivaroxaban were quantified using a validated ultra-performance liquid chromatography-tandem mass spectrometry assay with a lower limit of quantification of 2.5 pg/ml. RESULTS The microdosed FXaI cocktail showed similar pharmacokinetic parameters compared with published data, using normal therapeutic doses of each FXaI. Ketoconazole significantly increased exposure, with geometric mean AUC ratios of 1.90 (apixaban), 2.35 (edoxaban) and 2.27 (rivaroxaban). CONCLUSION The microdosed FXaI cocktail approach was able to precisely predict the drug interaction with ketoconazole. This is the first study that has been conducted to evaluate drug-drug interactions with a drug class, and the low administered doses also allow evaluation in vulnerable target populations. STUDY PROTOCOL EudraCT 2016-003024-23.
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18
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Mikus G, Foerster KI, Schaumaeker M, Lehmann M, Burhenne J, Haefeli WE. Application of a microdosed cocktail of 3 oral factor Xa inhibitors to study drug-drug interactions with different perpetrator drugs. Br J Clin Pharmacol 2020; 86:1632-1641. [PMID: 32159869 PMCID: PMC7373712 DOI: 10.1111/bcp.14277] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/20/2020] [Accepted: 03/03/2020] [Indexed: 12/13/2022] Open
Abstract
AIMS Using 3 different perpetrators the impact of voriconazole, cobicistat and rifampicin (single dose), we evaluated the suitability of a microdose cocktail of factor Xa inhibitors (FXaI; rivaroxaban, apixaban and edoxaban; 100 μg in total) to study drug-drug interactions. METHODS Three cohorts of 6 healthy volunteers received 2 treatments with microdoses of rivaroxaban, apixaban and edoxaban alone and with coadministration of 1 of the perpetrators. Plasma and urine concentrations of microdosed apixaban, edoxaban and rivaroxaban were quantified using a validated ultra-performance liquid chromatography-tandem mass spectrometry with a lower limit of quantification of 2.5 pg/mL. RESULTS Voriconazole caused only a minor interaction with apixaban and rivaroxaban, none with edoxaban. Cobicistat significantly increased exposure of all 3 FXaI with area under the plasma concentration-time curve ratios of 1.67 (apixaban), 1.74 (edoxaban) and 2.0 (rivaroxaban). A single dose of rifampicin decreased the volume of distribution and elimination half-life of all 3 FXaI. CONCLUSIONS The microdosed FXaI cocktail approach is able to generate drug interaction data and can help elucidating the mechanism involved in the clearance of the different victim drugs. This is a safe approach to concurrently study drug-drug interactions with a drug class. (EudraCT 2016-003024-23).
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Affiliation(s)
- Gerd Mikus
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Kathrin I. Foerster
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Marlene Schaumaeker
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Marie‐Louise Lehmann
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Walter E. Haefeli
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
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19
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Ariizumi S, Naito T, Hoshikawa K, Akutsu S, Saotome M, Maekawa Y, Kawakami J. Simple LC-MS/MS method using core-shell ODS microparticles for the simultaneous quantitation of edoxaban and its major metabolites in human plasma. J Chromatogr B Analyt Technol Biomed Life Sci 2020; 1146:122121. [DOI: 10.1016/j.jchromb.2020.122121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 11/28/2022]
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20
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Foerster KI, Hermann S, Mikus G, Haefeli WE. Drug-Drug Interactions with Direct Oral Anticoagulants. Clin Pharmacokinet 2020; 59:967-980. [PMID: 32157630 PMCID: PMC7403169 DOI: 10.1007/s40262-020-00879-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A large body of evidence suggests that not only direct anticoagulant effects but also major bleeding events and stroke prevention depend on plasma concentrations of direct oral anticoagulants (DOACs). Concomitant drugs that cause drug–drug interactions (DDIs) alter DOAC exposure by increasing or decreasing DOAC bioavailability and/or clearance; hence, they might affect the efficacy and safety of DOAC therapy. Patients with renal impairment already receive smaller DOAC maintenance doses because avoidance of elevated DOAC exposure might prevent serious bleeding events. For other causes of increased exposure such as DDIs, management is often less well-defined. Considering that DOAC patients are often older and have multiple co-morbidities, polypharmacy is highly prevalent. However, the effect of multiple drugs on DOAC exposure, and especially the impact of DDIs when concurring with drug–disease interactions as observed in renal impairment, has not been thoroughly elucidated. In order to provide effective and safe anticoagulation with DOACs, understanding the mechanisms and magnitude of DDIs appears relevant. Instead of avoiding drug combinations with DOACs, more DDI trials should be conducted and new strategies such as dose adjustments based on therapeutic drug monitoring should be investigated. However, dose adjustments based on concentration measurements cannot currently be recommended because evidence-based data are missing.
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Affiliation(s)
- Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Simon Hermann
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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Kustos SA, Fasinu PS. Direct-Acting Oral Anticoagulants and Their Reversal Agents-An Update. MEDICINES 2019; 6:medicines6040103. [PMID: 31618893 PMCID: PMC6963825 DOI: 10.3390/medicines6040103] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/10/2019] [Accepted: 10/14/2019] [Indexed: 12/13/2022]
Abstract
Background: Over the last ten years, a new class of drugs, known as the direct-acting oral anticoagulants (DOACs), have emerged at the forefront of anticoagulation therapy. Like the older generation anticoagulants, DOACs require specific reversal agents in cases of life-threatening bleeding or the need for high-risk surgery. Methods: Published literature was searched, and information extracted to provide an update on DOACS and their reversal agents. Results: The DOACs include the direct thrombin inhibitor—dabigatran, and the factor Xa inhibitors—rivaroxaban, apixaban, edoxaban, and betrixaban. These DOACs all have a rapid onset of action and each has a predictable therapeutic response requiring no monitoring, unlike the older anticoagulants, such as warfarin. Two reversal agents have been approved within the last five years: idarucizumab for the reversal of dabigatran, and andexanet alfa for the reversal of rivaroxaban and apixaban. Additionally, ciraparantag, a potential “universal” reversal agent, is currently under clinical development. Conclusions: A new generation of anticoagulants, the DOACs, and their reversal agents, are gaining prominence in clinical practice, having demonstrated superior efficacy and safety profiles. They are poised to replace traditional anticoagulants including warfarin.
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Affiliation(s)
- Stephanie A Kustos
- Department of Pharmaceutical Sciences, College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC 27506, USA.
| | - Pius S Fasinu
- Department of Pharmaceutical Sciences, College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC 27506, USA.
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Wang R, Sun X, Deng YS, Qiu XW. Effects of MDR1 1236C > T-2677G > T-3435C > T polymorphisms on the intracellular accumulation of tacrolimus, cyclosporine A, sirolimus and everolimus. Xenobiotica 2019; 49:1373-1378. [PMID: 30587068 DOI: 10.1080/00498254.2018.1563732] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
1. Overexpression of P-glycoprotein (P-gp, encoded by MDR1) mediates resistance to multiple immunosuppressors. Several common MDR1 variants (1236C > T, 2677G > T, 3435C > T) impact the efflux activity of P-gp-mediated substrates. We assessed the effect of these polymorphisms on the sensitivity, intracellular accumulation, and efflux of tacrolimus, cyclosporine A, sirolimus and everolimus in transfected LLC-PK1 cells. 2. LLC-PK1 cell lines were transfected with empty vector (pcDNA3.1) and recombinant MDR1T-T-T, MDR1C-T-T, MDR1C-G-T and MDR1C-G-C vectors, respectively and further screened in the presence of puromycin. The IC50 values, intracellular accumulation, and apparent permeability ratios of tacrolimus, cyclosporine A, sirolimus and everolimus were evaluated. 3. MDR1 overexpression increased the resistance of LLC-PK1 cells to tacrolimus, cyclosporine A, sirolimus and everolimus. The resistance of cells expressing MDR1C-G-C wild-type haplotypes to tacrolimus were increased compared to MDR1T-T-T, MDR1C-T-T, MDR1C-G-T variant haplotypes. The efflux ability of P-gp-mediated tacrolimus in cells transfected with MDR1C-G-C was higher than cells overexpressing MDR1T-T-T, MDR1C-T-T, MDR1C-G-T variant haplotypes. In addition, the resistance of cells expressing MDR1C-G-C wild-type haplotypes to sirolimus were increased compared to MDR1C-T-T, MDR1C-G-T variant haplotypes. The efflux ability of P-gp-mediated sirolimus in cells overexpressing MDR1C-G-C was higher than cells transfected with MDR1C-T-T, MDR1C-G-T variant haplotypes. 4. These findings indicate that wild-type MDR1 exports tacrolimus and sirolimus more efficiency than the MDR1T-T-T, MDR1C-T-T, MDR1C-G-T variant protein. This observation indicates that 1236C > T, 2677G > T, 3435C > T variant haplotypes drastically decrease the efflux ability of P-gp-mediated tacrolimus and sirolimus in a substrate-specific manner.
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Affiliation(s)
- Rong Wang
- a Nursing Department, Renmin Hospital of Wuhan University , Wuhan , China
| | - Xuan Sun
- a Nursing Department, Renmin Hospital of Wuhan University , Wuhan , China
| | - Yong-Shu Deng
- b Department of Cardiology, Renmin Hospital of Songzi City , Songzi , China
| | - Xu-Wen Qiu
- c Renmin Hospital of Songzi City , Songzi , China
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Brings A, Lehmann ML, Foerster KI, Burhenne J, Weiss J, Haefeli WE, Czock D. Perpetrator effects of ciclosporin (P-glycoprotein inhibitor) and its combination with fluconazole (CYP3A inhibitor) on the pharmacokinetics of rivaroxaban in healthy volunteers. Br J Clin Pharmacol 2019; 85:1528-1537. [PMID: 30912163 DOI: 10.1111/bcp.13934] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 03/01/2019] [Accepted: 03/20/2019] [Indexed: 12/25/2022] Open
Abstract
AIMS Rivaroxaban exposure is considerably increased by drugs that are combined P-glycoprotein (P-gp) and strong cytochrome P450 (CYP) 3A inhibitors (e.g. ketoconazole). The aim of the present study was to investigate the effects of the potent P-gp inhibitor ciclosporin and its combination with the moderate CYP3A inhibitor fluconazole on rivaroxaban pharmacokinetics and on CYP3A activity. METHODS Twelve healthy volunteers received 20 mg rivaroxaban orally alone, in combination with ciclosporin (dose-individualized oral regimen), and in combination with ciclosporin and fluconazole (400 mg day-1 orally). CYP3A4 activity was estimated using a midazolam microdose. Pharmacokinetics was analysed using noncompartmental and compartmental methods. RESULTS Compared to baseline, ciclosporin increased rivaroxaban average exposure by 47% (90% confidence interval 28-68%), maximum concentration by 104% (70-146%), and decreased CYP3A4 activity by 34% (25-42%). Ciclosporin combined with fluconazole increased rivaroxaban average exposure by 86% (58-119%) and maximum concentration by 115% (83-153%), which was considerably stronger than observed in historical controls receiving rivaroxaban with fluconazole alone, and decreased CYP3A4 activity by 79% (76-82%). CONCLUSION Patients treated with rivaroxaban in combination with single modulators of multiple elimination pathways or multiple modulators of single elimination pathways (CYP3A, P-gp) require particular care.
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Affiliation(s)
- Antonia Brings
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Marie-Louise Lehmann
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Johanna Weiss
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - David Czock
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
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Cervantes CE, Merino JL, Barrios V. Edoxaban for the prevention of stroke in patients with atrial fibrillation. Expert Rev Cardiovasc Ther 2019; 17:319-330. [DOI: 10.1080/14779072.2019.1598263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Carlos Escobar Cervantes
- Cardiology Service, Unidad de electrofisiología cardíaca robotizada, Hospital Universitario La Paz, Madrid, Spain
| | - José Luis Merino
- Cardiology Service, Unidad de electrofisiología cardíaca robotizada, Hospital Universitario La Paz, Madrid, Spain
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Kimoto E, Vourvahis M, Scialis RJ, Eng H, Rodrigues AD, Varma MVS. Mechanistic Evaluation of the Complex Drug-Drug Interactions of Maraviroc: Contribution of Cytochrome P450 3A, P-Glycoprotein and Organic Anion Transporting Polypeptide 1B1. Drug Metab Dispos 2019; 47:493-503. [DOI: 10.1124/dmd.118.085241] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 03/04/2019] [Indexed: 12/21/2022] Open
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Rusli N, Amanah A, Kaur G, Adenan MI, Sulaiman SF, Wahab HA, Tan ML. The inhibitory effects of mitragynine on P-glycoprotein in vitro. Naunyn Schmiedebergs Arch Pharmacol 2019; 392:481-496. [DOI: 10.1007/s00210-018-01605-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/14/2018] [Indexed: 12/13/2022]
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Gao YL, He B. ABCB1 1199G>A Polymorphism Affects the Intracellular Accumulation of Antidepressants in LLC-PK1 Recombinant Cell Lines. DNA Cell Biol 2018; 37:1055-1060. [PMID: 30256659 DOI: 10.1089/dna.2018.4391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yun-ling Gao
- Department of Research Section, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Biao He
- Department of Pharmacy, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
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Riess H, Prandoni P, Harder S, Kreher S, Bauersachs R. Direct oral anticoagulants for the treatment of venous thromboembolism in cancer patients: Potential for drug-drug interactions. Crit Rev Oncol Hematol 2018; 132:169-179. [PMID: 30447923 DOI: 10.1016/j.critrevonc.2018.09.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/30/2018] [Accepted: 09/25/2018] [Indexed: 12/19/2022] Open
Abstract
Patients with cancer are at high risk of developing venous thromboembolism (VTE). Although the recommended low molecular weight heparins (LMWHs) are more effective than vitamin K antagonists in treating VTE in patients with cancer, they have limitations and contraindications. Direct oral anticoagulants (DOACs) circumvent some of these limitations. Here, DOAC use for VTE treatment in patients receiving anticancer therapy is reviewed, focusing on metabolic and elimination pathways, potential drug-drug interactions and practical considerations. DOACs are typically substrates of the cytochrome P450-based metabolic pathways and/or ATP-binding cassette transporters. Although many cancer therapies influence these pathways, only a minority of these drugs interact with DOACs. Phase III DOAC trials provided encouraging safety and efficacy data for their use in cancer-associated thrombosis. Furthermore, numerous ongoing DOAC trials strive to gain a better understanding of the treatment of cancer-associated thrombosis and continue to support a role for DOACs in this setting.
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Affiliation(s)
- Hanno Riess
- Department of Haematology and Oncology, Charité - Universitätsmedizin Berlin, Germany.
| | | | - Sebastian Harder
- Institute of Clinical Pharmacology, University Hospital, Frankfurt, Germany
| | - Stephan Kreher
- Department of Haematology and Oncology, Charité - Universitätsmedizin Berlin, Germany
| | - Rupert Bauersachs
- Department of Vascular Medicine, Darmstadt, and Center for Thrombosis and Haemostasis, University Medical Centre, Mainz, Germany
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29
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Hodin S, Basset T, Jacqueroux E, Delezay O, Clotagatide A, Perek N, Mismetti P, Delavenne X. In Vitro Comparison of the Role of P-Glycoprotein and Breast Cancer Resistance Protein on Direct Oral Anticoagulants Disposition. Eur J Drug Metab Pharmacokinet 2018; 43:183-191. [PMID: 28895074 DOI: 10.1007/s13318-017-0434-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pharmacokinetics of direct oral anticoagulants (DOACs) are influenced by ATP-binding cassette (ABC) transporters such as P-glycoprotein (P-gp) and Breast Cancer Resistance Protein (BCRP). OBJECTIVES To better understand the role of transporters in DOAC disposition, we evaluated and compared the permeabilities and transport properties of these drugs. METHODS Bidirectional permeabilities of DOACs were investigated across Caco-2 cells monolayer. Transport assays were performed using different concentrations of DOAC and specific inhibitors of ABC transporters. Cell model functionality was evaluated by transport assay of two positive control substrates. RESULTS The results of transport assays suggest a concentration-dependent efflux of apixaban, dabigatran etexilate and edoxaban, whereas the efflux transport of rivaroxaban did not seem to depend on concentration. Verapamil, a strong inhibitor of P-gp, decreased DOAC efflux in the Caco-2 cell model by 12-87%, depending on the drug tested. Ko143 reduced BCRP-mediated DOAC efflux in Caco-2 cells by 46-76%. CONCLUSION This study allowed identification of three different profiles of ABC carrier-mediated transport: predominantly P-gp-dependent transport (dabigatran), preferential BCRP-dependent transport (apixaban) and approximately equivalent P-gp and BCRP-mediated transport (edoxaban and rivaroxaban).
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Affiliation(s)
- Sophie Hodin
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Étienne, France.,Université de Lyon, 42023, Saint-Étienne, France
| | - Thierry Basset
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Étienne, France.,Université de Lyon, 42023, Saint-Étienne, France.,Laboratoire de Pharmacologie-Toxicologie-Gaz du sang, Plateau de Biologie-Hôpital Nord, CHU de Saint-Etienne, 42055, Saint-Étienne, France
| | - Elodie Jacqueroux
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Étienne, France.,Université de Lyon, 42023, Saint-Étienne, France
| | - Olivier Delezay
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Étienne, France.,Université de Lyon, 42023, Saint-Étienne, France
| | - Anthony Clotagatide
- Service de Radiopharmacie, CHU de Saint-Etienne, 42055, Saint-Étienne, France
| | - Nathalie Perek
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Étienne, France.,Université de Lyon, 42023, Saint-Étienne, France
| | - Patrick Mismetti
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Étienne, France.,Université de Lyon, 42023, Saint-Étienne, France.,Unité de Recherche Clinique Innovation et Pharmacologie, CHU de Saint-Etienne, 42055, Saint-Étienne, France
| | - Xavier Delavenne
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, Saint-Étienne, France. .,Université de Lyon, 42023, Saint-Étienne, France. .,Laboratoire de Pharmacologie-Toxicologie-Gaz du sang, Plateau de Biologie-Hôpital Nord, CHU de Saint-Etienne, 42055, Saint-Étienne, France.
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Gelosa P, Castiglioni L, Tenconi M, Baldessin L, Racagni G, Corsini A, Bellosta S. Pharmacokinetic drug interactions of the non-vitamin K antagonist oral anticoagulants (NOACs). Pharmacol Res 2018; 135:60-79. [PMID: 30040996 DOI: 10.1016/j.phrs.2018.07.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 07/10/2018] [Accepted: 07/16/2018] [Indexed: 12/20/2022]
Abstract
The use of warfarin, the most commonly prescribed oral anticoagulant, is being questioned by clinicians worldwide due to warfarin several limitations (a limited therapeutic window and significant variability in dose-response among individuals, in addition to a potential for drug-drug interactions). Therefore, the need for non-vitamin K antagonist oral anticoagulants (NOACs) with a rapid onset of antithrombotic effects and a predictable pharmacokinetic (PK) and pharmacodynamic (PD) profile led to the approval of five new drugs: the direct factor Xa (F-Xa) inhibitors rivaroxaban, apixaban, edoxaban and betrixaban (newly approved by FDA) and the direct thrombin (factor-IIa) inhibitor dabigatran etexilate. The advantages of NOACs over warfarin are a fixed-dosage, the absence of the need for drug monitoring for changes in anti-coagulation and fewer clinically significant PK and PD drug-drug interactions. NOACs exposure will likely be increased by the administration of strong P-glycoprotein (P-gp) and cytochrome P450 (CYP) 3A4-inhibitors and may increase the risk of bleeds. On the contrary, P-gp inducers could significantly decrease the NOACs plasma concentration with an associated reduction in their anticoagulant effects. This manuscript gives an overview of NOACs PK profiles and their drug-drug interactions potential. This is meant to be of help to physicians in choosing the best therapeutic approach for their patients.
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Affiliation(s)
- Paolo Gelosa
- Centro Cardiologico Monzino IRCCS, Via C. Parea, 4, 20138 Milan, Italy.
| | - Laura Castiglioni
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti 9, 20133 Milan, Italy.
| | - Marco Tenconi
- EDRA S.p.A., Via G. Spadolini, 7, 20141 Milan, Italy.
| | | | - Giorgio Racagni
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti 9, 20133 Milan, Italy.
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti 9, 20133 Milan, Italy; IRCCS MultiMedica, via G. Fantoli 16, 20138 Milan, Italy.
| | - Stefano Bellosta
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti 9, 20133 Milan, Italy; IRCCS MultiMedica, via G. Fantoli 16, 20138 Milan, Italy.
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Oishi M, Takano Y, Torita Y, Malhotra B, Chiba K. Physiological based pharmacokinetic modeling to estimate in vivo Ki of ketoconazole on renal P-gp using human drug-drug interaction study result of fesoterodine and ketoconazole. Drug Metab Pharmacokinet 2018; 33:90-95. [PMID: 29338933 DOI: 10.1016/j.dmpk.2017.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 11/10/2017] [Accepted: 11/13/2017] [Indexed: 10/18/2022]
Abstract
This study was conducted to estimate in vivo inhibition constant (Ki) of ketoconazole on renal P-glycoprotein (P-gp) using human drug-drug interaction (DDI) study result of fesoterodine and ketoconazole. Fesoterodine is a prodrug which is extensively hydrolyzed by non-specific esterases to the active metabolite 5-hydroxymethyl tolterodine (5-HMT). 5-HMT is then further metabolized via Cytochrome P450 (CYP) 2D6 and CYP3A4. It is reported that 5-HMT is a substrate of P-gp whereas fesoterodine is not. Renal clearance of 5-HMT is approximately two-times greater than renal glomerular filtration rate. This suggests the possibility that renal clearance of 5-HMT involves secretion by P-gp. Utilizing the available pharmacokinetic characteristics of fesoterodine and 5-HMT, we estimated in vivo Ki of ketoconazole on P-gp at kidney based on DDI study data using physiologically-based pharmacokinetic approach. The estimated in vivo Ki of ketoconazole for hepatic CYP3A4 (6.64 ng/mL) was consistent with the reported values. The in vivo Ki of ketoconazole for renal P-gp was successfully estimated as 2.27 ng/mL, which was notably lower than reported in vitro 50% inhibitory concentration (IC50) values ranged 223-2440 ng/mL due to different condition between in vitro and in vivo.
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Affiliation(s)
- Masayo Oishi
- Clinical Pharmacology, Clinical Research, Pfizer Global R&D, Tokyo Laboratories, Pfizer Japan Inc., Tokyo, Japan
| | - Yuma Takano
- Department of Drug Development Science & Clinical Evaluation, Keio University of Pharmacy, Tokyo, Japan
| | - Yutaka Torita
- Department of Drug Development Science & Clinical Evaluation, Keio University of Pharmacy, Tokyo, Japan
| | | | - Koji Chiba
- Laboratory of Clinical Pharmacology, Yokohama University of Pharmacy, Kanagawa, Japan.
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Eikelboom J, Weitz JI. Incorporating edoxaban into the choice of anticoagulants for atrial fibrillation. Thromb Haemost 2017; 115:257-70. [DOI: 10.1160/th15-02-0181] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 09/10/2015] [Indexed: 12/24/2022]
Abstract
SummaryThe non-vitamin K antagonist oral anticoagulants (NOACs) are replacing warfarin for stroke prevention in many patients with nonvalvular atrial fibrillation. Edoxaban, an oral factor Xa inhibitor, is the newest entrant in this class. Results of the Effective Anticoagulation with Factor Xa Next Generation in Atrial Fibrillation (ENGAGE AF) study demonstrate that edoxaban is noninferior to warfarin for prevention of stroke and systemic embolic events, and is associated with significantly less major bleeding, including intracranial bleeding, and reduced cardiovascular mortality. With a net clinical benefit over warfarin, edoxaban is well positioned as a choice among the NOACs, which include dabigatran, rivaroxaban, and apixaban. But how will clinicians choose amongst them? The purpose of this paper is to (a) place the ENGAGE AF trial results into context with results of the studies with the other NOACs, and (b) aid clinicians in selection of the right anticoagulant for the right atrial fibrillation patient.
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BCRP/ABCG2 and high-alert medications: Biochemical, pharmacokinetic, pharmacogenetic, and clinical implications. Biochem Pharmacol 2017; 147:201-210. [PMID: 29031817 DOI: 10.1016/j.bcp.2017.10.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 10/11/2017] [Indexed: 01/14/2023]
Abstract
The human breast cancer resistance protein (BCRP/ABCG2) is an ATP-binding cassette efflux transporter that uses ATP hydrolysis to expel xenobiotics from cells, including anti-cancer medications. It is expressed in the gastrointestinal tract, liver, kidney, and brain endothelium. Thus, ABCG2 functions as a tissue barrier to drug transport that strongly influences the pharmacokinetics of substrate medications. Genetic polymorphisms of ABCG2 are closely related to inter-individual variations in therapeutic performance. The common single nucleotide polymorphism c.421C>A, p.Q141K reduces cell surface expression of ABCG2 protein, resulting in lower efflux of substrates. Consequently, a higher plasma concentration of substrate is observed in patients carrying an ABCG2 c.421C>A allele. Detailed pharmacokinetic analyses have revealed that altered intestinal absorption is responsible for the distinct pharmacokinetics of ABCG2 substrates in genetic carriers of the ABCG2 c.421C>A polymorphism. Recent studies have focused on the high-alert medications among ABCG2 substrates (defined as those with high risk of adverse events), such as tyrosine kinase inhibitors (TKIs) and direct oral anti-coagulants (DOACs). For these high-alert medications, inter-individual variation may be closely related to the severity of side effects. In addition, ethnic differences in the frequency of ABCG2 c.421C>A have been reported, with markedly higher frequency in East Asian (∼30-60%) than Caucasian and African-American populations (∼5-10%). Therefore, ABCG2 polymorphisms must be considered not only in the drug development phase, but also in clinical practice. In the present review, we provide an update of basic and clinical knowledge on genetic polymorphisms of ABCG2.
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Pharmacokinetics and Pharmacodynamics of Edoxaban, a Non-Vitamin K Antagonist Oral Anticoagulant that Inhibits Clotting Factor Xa. Clin Pharmacokinet 2017; 55:641-55. [PMID: 26620048 PMCID: PMC4875962 DOI: 10.1007/s40262-015-0342-7] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Edoxaban, a once daily non-vitamin K antagonist oral anticoagulant, is a direct, selective, reversible inhibitor of factor Xa (FXa). In healthy subjects, single oral doses of edoxaban result in peak plasma concentrations within 1.0–2.0 h of administration, followed by a biphasic decline. Exposure is approximately dose proportional for once daily doses of 15–150 mg. Edoxaban is predominantly absorbed from the upper gastrointestinal tract, and oral bioavailability is approximately 62 %. Food does not affect total exposure to edoxaban. The terminal elimination half-life in healthy subjects ranges from 10 to 14 h, with minimal accumulation upon repeat once daily dosing up to doses of 120 mg. The steady-state volume of distribution is approximately 107 L, and total clearance is approximately 22 L/h; renal clearance accounts for approximately 50 % of total clearance, while metabolism and biliary secretion account for the remaining 50 %. Intrinsic factors, such as age, sex and race, do not affect edoxaban pharmacokinetics after renal function is taken into account. Oral administration of edoxaban results in rapid changes in anticoagulatory biomarkers, with peak effects on anticoagulation markers (such as anti-FXa), the prothrombin time and the activated partial thromboplastin time occurring within 1–2 h of dosing.
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Oertel LB, Fogerty AE. Use of direct oral anticoagulants for stroke prevention in elderly patients with nonvalvular atrial fibrillation. J Am Assoc Nurse Pract 2017; 29:551-561. [PMID: 28805310 DOI: 10.1002/2327-6924.12494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/13/2017] [Accepted: 06/17/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Lynn B Oertel
- Anticoagulant Management Service, Department of Nursing, Massachusetts General Hospital, Boston, Massachusetts
| | - Annemarie E Fogerty
- Department of Hematology, Massachusetts General Hospital, Boston, Massachusetts
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Abstract
Transporters in proximal renal tubules contribute to the disposition of numerous drugs. Furthermore, the molecular mechanisms of tubular secretion have been progressively elucidated during the past decades. Organic anions tend to be secreted by the transport proteins OAT1, OAT3 and OATP4C1 on the basolateral side of tubular cells, and multidrug resistance protein (MRP) 2, MRP4, OATP1A2 and breast cancer resistance protein (BCRP) on the apical side. Organic cations are secreted by organic cation transporter (OCT) 2 on the basolateral side, and multidrug and toxic compound extrusion (MATE) proteins MATE1, MATE2/2-K, P-glycoprotein, organic cation and carnitine transporter (OCTN) 1 and OCTN2 on the apical side. Significant drug-drug interactions (DDIs) may affect any of these transporters, altering the clearance and, consequently, the efficacy and/or toxicity of substrate drugs. Interactions at the level of basolateral transporters typically decrease the clearance of the victim drug, causing higher systemic exposure. Interactions at the apical level can also lower drug clearance, but may be associated with higher renal toxicity, due to intracellular accumulation. Whereas the importance of glomerular filtration in drug disposition is largely appreciated among clinicians, DDIs involving renal transporters are less well recognized. This review summarizes current knowledge on the roles, quantitative importance and clinical relevance of these transporters in drug therapy. It proposes an approach based on substrate-inhibitor associations for predicting potential tubular-based DDIs and preventing their adverse consequences. We provide a comprehensive list of known drug interactions with renally-expressed transporters. While many of these interactions have limited clinical consequences, some involving high-risk drugs (e.g. methotrexate) definitely deserve the attention of prescribers.
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Affiliation(s)
- Anton Ivanyuk
- Division of Clinical Pharmacology, Lausanne University Hospital (CHUV), Bugnon 17, 1011, Lausanne, Switzerland.
| | - Françoise Livio
- Division of Clinical Pharmacology, Lausanne University Hospital (CHUV), Bugnon 17, 1011, Lausanne, Switzerland
| | - Jérôme Biollaz
- Division of Clinical Pharmacology, Lausanne University Hospital (CHUV), Bugnon 17, 1011, Lausanne, Switzerland
| | - Thierry Buclin
- Division of Clinical Pharmacology, Lausanne University Hospital (CHUV), Bugnon 17, 1011, Lausanne, Switzerland
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Abstract
Drug-drug interactions (DDIs) occur commonly and may lead to severe adverse drug reactions if not handled appropriately. Considerable information to support clinical decision making regarding potential DDIs is available in the literature and through various systems providing electronic decision support for healthcare providers. The challenge for the prescribing physician lies in sorting out the evidence and identifying those drugs for which potential interactions are likely to become clinically manifest. P-glycoprotein (P-gp) is a drug transporting protein that is found in the plasma membranes in cells of barrier and elimination organs, and plays a role in drug absorption and excretion. Increasingly, P-gp has been acknowledged as an important player in potential DDIs and a growing body of information on the role of this transporter in DDIs has become available from research and from the drug approval process. This has led to a clear need for a comprehensive review of P-gp-mediated DDIs with a focus on highlighting the drugs that are likely to lead to clinically relevant DDIs. The objective of this review is to provide information for identifying and interpreting evidence of P-gp-mediated DDIs and to suggest a classification for individual drugs based on both in vitro and in vivo evidence (substrates, inhibitors and inducers). Further, various ways of handling potential DDIs in clinical practice are described and exemplified in relation to drugs interfering with P-gp.
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39
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Okudaira N. Evaluation of New Chemical Entities as Substrates of Liver Transporters in the Pharmaceutical Industry: Response to Regulatory Requirements and Future Steps. J Pharm Sci 2017; 106:2251-2256. [PMID: 28533120 DOI: 10.1016/j.xphs.2017.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 05/04/2017] [Accepted: 05/05/2017] [Indexed: 10/19/2022]
Abstract
This article discusses the evaluation of drug candidates as hepatic transporter substrates. Recently, research on the applications of hepatic transporters in the pharmaceutical industry has improved to meet the requirements of the regulatory guidelines for the evaluation of drug interactions. To identify the risk of transporter-mediated drug-drug interactions at an early stage of drug development, we used a strategy of reviewing the in vivo animal pharmacokinetics and tissue distribution data obtained in the discovery stage together with the in vitro data obtained for regulatory submission. In the context of nonclinical evaluation of new chemical entities as medicines, we believe that transporter studies are emerging as a key strategy to predict their pharmacological and toxicological effects. In combination with the recent progress in systems approaches, the estimation of effective concentrations in the target tissues, by using mathematical models to describe the transporter-mediated distribution and elimination, has enabled us to identify promising compounds for clinical development at the discovery stage.
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Affiliation(s)
- Noriko Okudaira
- Drug Metabolism & Pharmacokinetic Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan.
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40
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Chan NC, Eikelboom JW, Weitz JI. Evolving Treatments for Arterial and Venous Thrombosis: Role of the Direct Oral Anticoagulants. Circ Res 2017; 118:1409-24. [PMID: 27126650 DOI: 10.1161/circresaha.116.306925] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 04/02/2016] [Indexed: 01/23/2023]
Abstract
The direct oral anticoagulants (DOACs) represent a major advance in oral anticoagulant therapy and have replaced the vitamin K antagonists as the preferred treatment for many indications. By simplifying long-term anticoagulant therapy and improving its safety, the DOACs have the potential to reduce the global burden of thrombosis. Postmarketing studies suggest that the favorable results achieved with DOACs in the randomized controlled trials can be readily translated into practice, but highlight the need for appropriate patient, drug and dose selection, and careful follow-up. Leveraging on their success to date, ongoing studies are assessing the utility of DOACs for the prevention of thrombosis in patients with embolic stroke of unknown source, heart failure, coronary artery disease, peripheral artery disease, antiphospholipid syndrome, and cancer. The purpose of this article is to (1) review the pharmacology of the DOACs, (2) describe the advantages of the DOACs over vitamin K antagonists, (3) summarize the experience with the DOACs in established indications, (4) highlight current challenges and limitations, (5) highlight potential new indications; and (6) identify future directions for anticoagulant therapy.
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Affiliation(s)
- Noel C Chan
- From the Population Health Research Institute (N.C.C., J.W.E.) and Department of Medicine (J.W.E., J.I.W.), McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.W.E., J.I.W.); and Department of Medicine, Monash University, Clayton, Victoria, Australia (N.C.C.).
| | - John W Eikelboom
- From the Population Health Research Institute (N.C.C., J.W.E.) and Department of Medicine (J.W.E., J.I.W.), McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.W.E., J.I.W.); and Department of Medicine, Monash University, Clayton, Victoria, Australia (N.C.C.)
| | - Jeffrey I Weitz
- From the Population Health Research Institute (N.C.C., J.W.E.) and Department of Medicine (J.W.E., J.I.W.), McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.W.E., J.I.W.); and Department of Medicine, Monash University, Clayton, Victoria, Australia (N.C.C.)
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41
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Hakeam HA, Al-Sanea N. Effect of major gastrointestinal tract surgery on the absorption and efficacy of direct acting oral anticoagulants (DOACs). J Thromb Thrombolysis 2017; 43:343-351. [DOI: 10.1007/s11239-016-1465-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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42
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Salerno DM, Tsapepas D, Papachristos A, Chang JH, Martin S, Hardy MA, McKeen J. Direct oral anticoagulant considerations in solid organ transplantation: A review. Clin Transplant 2016; 31. [PMID: 27859621 DOI: 10.1111/ctr.12873] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2016] [Indexed: 12/17/2022]
Abstract
For more than 60 years, warfarin was the only oral anticoagulation agent available for use in the United States. In many recent clinical trials, several direct oral anticoagulants (DOACs) demonstrated similar efficacy with an equal or superior safety profile, with some other notable benefits. The DOACs have lower inter- and intrapatient variability, much shorter half-lives, and less known drug-drug and drug-food interactions as compared to warfarin. Despite these demonstrated benefits, the use of DOACs has not gained uniform acceptance because of lack of supportive data in special patient populations, including recipients of solid organ transplants maintained on immunosuppression. This review describes the properties of several novel DOACs including their pharmacology and mechanisms of action as they relate to use among solid organ transplant recipients. We have particularly focused on (i) dosing in patients with impaired renal and hepatic function; (ii) considerations for drug-drug interactions with immunosuppressive medications; and (iii) management of the anticoagulated patients at the time of unplanned surgery. The risks and benefits of the use of DOACs in solid organ transplant recipients should be carefully evaluated prior to the introduction of these agents in this highly distinct patient population.
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Affiliation(s)
- David M Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Demetra Tsapepas
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY, USA.,Department of Surgery, Division of Abdominal Transplantation, Columbia University Medical Center, New York, NY, USA
| | | | - Jae-Hyung Chang
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA
| | - Spencer Martin
- Department of Pharmacy, Hartford Hospital, Hartford, CT, USA
| | - Mark A Hardy
- Department of Surgery, Division of Abdominal Transplantation, Columbia University Medical Center, New York, NY, USA
| | - Jaclyn McKeen
- Department of Pharmacy, Hackensack University Medical Center, Hackensack, NJ, USA
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43
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Vandell AG, Lee J, Shi M, Rubets I, Brown KS, Walker JR. An integrated pharmacokinetic/pharmacogenomic analysis of ABCB1 and SLCO1B1 polymorphisms on edoxaban exposure. THE PHARMACOGENOMICS JOURNAL 2016; 18:153-159. [PMID: 27897269 PMCID: PMC5817390 DOI: 10.1038/tpj.2016.82] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 07/01/2016] [Accepted: 08/31/2016] [Indexed: 12/14/2022]
Abstract
Edoxaban and its low-abundance, active metabolite M4 are substrates of P-glycoprotein (P-gp; MDR1) and organic anion transporter protein 1B1 (OATP1B1), respectively, and pharmacological inhibitors of P-gp and OATP1B1 can affect edoxaban and M4 pharmacokinetics (PK). In this integrated pharmacogenomic analysis, genotype and concentration-time data from 458 healthy volunteers in 14 completed phase 1 studies were pooled to examine the impact on edoxaban PK parameters of allelic variants of ABCB1 (rs1045642: C3435T) and SLCO1B1 (rs4149056: T521C), which encode for P-gp and OATP1B1. Although some pharmacologic inhibitors of P-gp and OATP1B1 increase edoxaban exposure, neither the ABCB1 C3435T nor the SLCO1B1 T521C polymorphism affected edoxaban PK. A slight elevation in M4 exposure was observed among SLCO1B1 C-allele carriers; however, this elevation is unlikely to be clinically significant as plasma M4 concentrations comprise <10% of total edoxaban levels.
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Affiliation(s)
- A G Vandell
- Translational Medicine & Clinical Pharmacology, Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | - J Lee
- Translational Medicine & Clinical Pharmacology, Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | - M Shi
- Translational Medicine & Clinical Pharmacology, Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | - I Rubets
- Pharsight Consulting Services, Montreal, Quebec, Canada
| | - K S Brown
- Translational Medicine & Clinical Pharmacology, Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | - J R Walker
- Translational Medicine & Clinical Pharmacology, Daiichi Sankyo Pharma Development, Edison, NJ, USA
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44
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Interactions between non-vitamin K oral anticoagulants and antiepileptic drugs. Epilepsy Res 2016; 126:98-101. [DOI: 10.1016/j.eplepsyres.2016.06.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/01/2016] [Accepted: 06/24/2016] [Indexed: 01/16/2023]
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45
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Parasrampuria DA, Mendell J, Shi M, Matsushima N, Zahir H, Truitt K. Edoxaban drug-drug interactions with ketoconazole, erythromycin, and cyclosporine. Br J Clin Pharmacol 2016; 82:1591-1600. [PMID: 27530188 PMCID: PMC5099547 DOI: 10.1111/bcp.13092] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/05/2016] [Accepted: 08/08/2016] [Indexed: 01/12/2023] Open
Abstract
AIMS Edoxaban, a novel factor Xa inhibitor, is a substrate of cytochrome P450 3 A4 (CYP3A4) and the efflux transporter P-glycoprotein (P-gp). Three edoxaban drug-drug interaction studies examined the effects of P-gp inhibitors with varying degrees of CYP3A4 inhibition. METHODS In each study, healthy subjects received a single oral dose of 60 mg edoxaban with or without an oral dual P-gp/CYP3A4 inhibitor as follows: ketoconazole 400 mg once daily for 7 days, edoxaban on day 4; erythromycin 500 mg four times daily for 8 days, edoxaban on day 7; or single dose of cyclosporine 500 mg with edoxaban. Serial plasma samples were obtained for pharmacokinetics and pharmacodynamics. Safety was assessed throughout the study. RESULTS Coadministration of ketoconazole, erythromycin, or cyclosporine increased edoxaban total exposure by 87%, 85%, and 73%, respectively, and the peak concentration by 89%, 68%, and 74%, respectively, compared with edoxaban alone. The half-life did not change appreciably. Exposure of M4, the major active edoxaban metabolite, was consistent when edoxaban was administered alone or with ketoconazole and erythromycin. With cyclosporine, M4 total exposure increased by 6.9-fold and peak exposure by 8.7-fold, suggesting an additional interaction. Pharmacodynamic effects were reflective of increased edoxaban exposure. No clinically significant adverse events were observed. CONCLUSIONS Administration of dual inhibitors of P-gp and CYP3A4 increased edoxaban exposure by less than two-fold. This effect appears to be primarily due to inhibition of P-gp. The impact of CYP3A4 inhibition appears to be less pronounced, and its contribution to total clearance appears limited in healthy subjects.
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Affiliation(s)
| | - Jeanne Mendell
- Daiichi Sankyo Pharma Development, Edison, New Jersey, USA
| | - Minggao Shi
- Daiichi Sankyo Pharma Development, Edison, New Jersey, USA
| | | | - Hamim Zahir
- Daiichi Sankyo Pharma Development, Edison, New Jersey, USA
| | - Kenneth Truitt
- Daiichi Sankyo Pharma Development, Edison, New Jersey, USA
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46
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Masjuan J, DeFelipe A. Secondary prevention in non-valvular atrial fibrillation patients: a practical approach with edoxaban. Int J Neurosci 2016; 127:716-725. [DOI: 10.1080/00207454.2016.1232256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Jaime Masjuan
- Servicio de Neurologia, Hospital Universitario Ramon y Cajal, Madrid, Spain
- Instituto de Investigación del Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
- Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Alicia DeFelipe
- Servicio de Neurologia, Hospital Universitario Ramon y Cajal, Madrid, Spain
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47
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Abstract
Edoxaban (Lixiana, Savaysa) is an oral, direct factor Xa inhibitor which has recently been approved for use in the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) [collectively, venous thromboembolism (VTE)] and for the prevention of recurrent VTE. This article reviews the pharmacological properties of edoxaban as well as its tolerability and therapeutic efficacy in the treatment and prevention of recurrent VTE events. As demonstrated in the pivotal Hokusai-VTE phase III trial, once-daily edoxaban after initial treatment with heparin was non-inferior to standard therapy with heparin/warfarin in preventing recurrent VTE events and was associated with a significantly lower risk of clinically relevant bleeding than the traditional therapy. Edoxaban shares the advantages of other direct oral anticoagulants (DOACs) over traditional therapies, including the lack of requirement for routine coagulation monitoring, a rapid onset and offset of action, and few drug-drug interactions. It offers the convenience of once-daily dosing, can be taken without regard to food and allows for a dose reduction in patients with certain clinical features, such as moderate renal impairment or low body weight. In conclusion, edoxaban represents an effective and potentially safer alternative to traditional vitamin K antagonist therapy for the treatment and prevention of recurrent VTE. Its recent approval expands the range of DOAC agents for recurrent VTE, further facilitating treatment individualization.
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Affiliation(s)
- Matt Shirley
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
| | - Sohita Dhillon
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand
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48
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Voukalis C, Lip GYH, Shantsila E. Drug-drug interactions of non-vitamin K oral anticoagulants. Expert Opin Drug Metab Toxicol 2016; 12:1445-1461. [PMID: 27535163 DOI: 10.1080/17425255.2016.1225037] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The approval of non-vitamin K oral anticoagulants (NOACs) as antithrombotic alternatives to vitamin K antagonists (VKAs) has changed clinical practice. However, the efficacy and safety of the four most commonly used NOACs (dabigatran, rivaroxaban, apixaban and edoxaban) might be compromised by co-administration of other medications used for various major comorbidities. Dose adjustment of the NOACs may be needed to avert cases of concomitant medication affecting NOACs absorption, metabolism and coagulation. Areas covered: This review summarizes the current knowledge regarding drug-drug interactions of NOACs in order to guide health professionals regarding the dose modification required if the NOACs are co-administered with other medication with potential significant interactions. The data were acquired from searches of PubMed and also from the NOAC reports to the European Medicines Agency and Food and Drug Administration Agency. Expert opinion: Most of the studies in this field have been organized by pharmaceutical companies. Independent research and registries will provide more information in the near future about the drug-drug interactions of NOACs. P-glycoprotein transporter and cytochrome P450 enzyme complexes appear to be the main pathways where the most drug-drug interactions with NOACs occur.
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Affiliation(s)
- Christos Voukalis
- a University of Birmingham Institute of Cardiovascular Sciences, City Hospital , Birmingham , UK
| | - Gregory Y H Lip
- a University of Birmingham Institute of Cardiovascular Sciences, City Hospital , Birmingham , UK
| | - Eduard Shantsila
- a University of Birmingham Institute of Cardiovascular Sciences, City Hospital , Birmingham , UK
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49
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Mendell J, Chen S, He L, Desai M, Parasramupria DA. The effect of rifampin on the pharmacokinetics of edoxaban in healthy adults. Clin Drug Investig 2016; 35:447-53. [PMID: 26068927 PMCID: PMC4488474 DOI: 10.1007/s40261-015-0298-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background and Objective The oral direct factor Xa inhibitor edoxaban is a P-glycoprotein (P-gp) substrate metabolized via carboxylesterase-1 and cytochrome P450 (CYP) 3A4/5. The effect of rifampin-induced induction of P-gp and CYP3A4/5 on transport and metabolism of edoxaban through the CYP3A4/5 pathway was investigated in a single-dose edoxaban study. Methods This was a phase 1, open-label, two-treatment, two-period, single-sequence drug interaction study in healthy adults. All subjects received a single oral 60 mg edoxaban dose in period 1, and 7 days of 600 mg rifampin (2 × 300 mg capsules once daily) with a single oral edoxaban 60 mg dose administered concomitantly on day 7 in period 2. A 6-day washout period separated the treatments. Plasma concentrations of edoxaban and its metabolites M4 and M6 were measured, and limited assessments of pharmacodynamic markers of coagulation were performed. Results In total, 34 healthy subjects were enrolled; 32 completed the study. Coadministration of rifampin with edoxaban decreased edoxaban exposure but increased active metabolite exposure. Rifampin increased apparent oral clearance of edoxaban by 33 % and decreased its half-life by 50 %. Anticoagulant effects based on the prothrombin time (PT) and the activated partial thromboplastin time (aPTT) with and without rifampin at early time points were maintained to a greater-than-expected degree than with edoxaban exposure alone, presumably because of an increased contribution from the active metabolites. Edoxaban was well tolerated in this healthy adult population. Conclusions Rifampin reduced exposure to edoxaban while increasing exposure to its active metabolites M4 and M6. PT and aPTT at early time points did not change appreciably; however, the data should be interpreted with caution.
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Affiliation(s)
- Jeanne Mendell
- Daiichi Sankyo Pharma Development, 399 Thornall Street, Edison, NJ, 08837, USA,
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50
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Barrios V, Escobar C. Implications of edoxaban in the prevention and treatment of thromboembolic complications in clinical practice. Future Cardiol 2016; 12:419-33. [DOI: 10.2217/fca-2016-0021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Edoxaban is a once-daily oral inhibitor of factor Xa, currently indicated to reduce the risk of stroke or systemic embolism in nonvalvular atrial fibrillation patients and for the treatment and prevention of venous thromboembolism (EMA, FDA and Japan). The ENGAGE AF-TIMI 48 and the Hokusai-VTE trials demonstrated that edoxaban was at least as effective as warfarin for the prevention of stroke or systemic embolism in nonvalvular atrial fibrillation patients, as well as for the prevention and treatment of venous thromboembolism, but with a lesser risk of bleeding in both cases. In addition, it seems a cost-effective strategy for the management of this population. In this review, the implications of the most recent available evidence about edoxaban in clinical practice will be updated.
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Affiliation(s)
- Vivencio Barrios
- Department of Cardiology, University Hospital Ramon y Cajal, Alcala University, Madrid, Spain
| | - Carlos Escobar
- Cardiology Department, University Hospital La Paz Madrid, Spain
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