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Möhlmann JE, Ezzafzafi S, Lindemans CA, Jansen MHA, Nierkens S, Huitema ADR, van Luin M. Pharmacokinetics and Pharmacodynamics of Systemic Corticosteroids in Autoimmune and Inflammatory Diseases: A Review of Current Evidence. Clin Pharmacokinet 2024; 63:1251-1270. [PMID: 39264575 PMCID: PMC11450095 DOI: 10.1007/s40262-024-01419-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND AND OBJECTIVE Systemic corticosteroids have a long history of use in the treatment of autoimmune and inflammatory diseases. Both efficacy and safety show large interindividual variability (IIV), suggesting that corticosteroids may have the potential for individualised dosing strategies to optimise therapy. This systematic review aims to provide an overview of current evidence on the pharmacokinetic (PK) and pharmacodynamic (PD) relationships of systemic corticosteroids in patients with autoimmune and inflammatory diseases. METHODS A systematic literature search was conducted in PubMed and Embase for PK/PD studies of systemic corticosteroids in autoimmune and inflammatory diseases in humans published until December 2023. Studies were scored from 1 to 5 according to criteria for the levels of evidence, as inspired by the Oxford Centre for Evidence-Based Medicine. RESULTS Twelve studies (1981-2016) were included. The majority of these studies had a small sample size. The corticosteroids involved were prednisone, prednisolone, methylprednisolone and budesonide. Substantial IIV of corticosteroid PK was described in all studies. Evidence for a relationship between the PK of corticosteroids and efficacy was inconclusive and limited. However, there was some evidence for a relationship between the PK of prednisolone and the severity of Cushingoid features. CONCLUSION There is insufficient evidence to draw firm conclusions on the potential associations between PK and clinical outcome of systemic corticosteroid treatment in autoimmune and inflammatory diseases. This is remarkable given the many decades that steroid drugs have been used in clinical care. Prospective research is recommended with robust and well-defined cohorts to fully quantify the PK/PD associations of corticosteroids.
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Affiliation(s)
- Julia E Möhlmann
- Department of Clinical Pharmacy, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands.
| | - Solaiman Ezzafzafi
- Department of Clinical Pharmacy, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Caroline A Lindemans
- Department of Stem Cell Transplantation, Princess Máxima Centre for Paediatric Oncology, Utrecht, The Netherlands
- Department of Paediatrics, Wilhelmina Children's Hospital, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Marc H A Jansen
- Department of Paediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Stefan Nierkens
- Department of Stem Cell Transplantation, Princess Máxima Centre for Paediatric Oncology, Utrecht, The Netherlands
- Department of Translational Immunology, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Centre for Paediatric Oncology, Utrecht, The Netherlands
- Department of Pharmacy and Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Matthijs van Luin
- Department of Clinical Pharmacy, University Medical Centre Utrecht, University Utrecht, Utrecht, The Netherlands
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Curkovic I, Egbring M, Kullak-Ublick GA. Risks of inflammatory bowel disease treatment with glucocorticosteroids and aminosalicylates. Dig Dis 2013; 31:368-73. [PMID: 24246990 DOI: 10.1159/000354699] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Glucocorticosteroids and aminosalicylates, mainly mesalazine (5-ASA), are both standard therapeutics in the treatment of inflammatory bowel disease (IBD) patients. The glucocorticosteroids are highly effective in inducing remission in both ulcerative colitis and Crohn's disease, but their use is limited by the high incidence and the potentially serious nature of adverse events. In an attempt to limit systemic side effects, rapidly metabolized corticosteroids such as budesonide have been introduced. The safety profile of aminosalicylates differs between the formulations. METHODS We summarize the potential risks associated with glucocorticosteroid and aminosalicylate therapy in IBDs. RESULTS The numerous adverse events of glucocorticosteroids, particularly at high doses and prolonged treatment, include opportunistic infections, diabetes mellitus, hypertension, ocular effects (glaucoma and cataracts), psychiatric complications, hypothalamic-pituitary-adrenal axis suppression and increased fracture risk. Partially, these systemic adverse events occur with budesonide, which only has a low systemic exposure. The safety profile of 5-ASA is comparable to placebo and superior to the old aminosalicylate prodrug sulfasalazine, which had a significantly higher incidence of intolerance reactions including allergic rashes. Only in rare cases has nephrotoxicity such as interstitial nephritis been associated with 5-ASA. CONCLUSION Considering the toxicity profile of conventional glucocorticosteroids, one primary goal of treatment in IBD should be corticosteroid-free remission. Therapy with budesonide may result in a better safety profile. 5-ASA treatment is usually well tolerated, but with regard to the rare nephrotoxic events, it is advisable to assess renal function before and during treatment with 5-ASA.
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Affiliation(s)
- Ivanka Curkovic
- Department of Clinical Pharmacology and Toxicology, University Hospital Zürich, Zürich, Switzerland
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Wolk O, Epstein S, Ioffe-Dahan V, Ben-Shabat S, Dahan A. New targeting strategies in drug therapy of inflammatory bowel disease: mechanistic approaches and opportunities. Expert Opin Drug Deliv 2013; 10:1275-86. [PMID: 23721560 DOI: 10.1517/17425247.2013.800480] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Inflammatory bowel disease (IBD) is an exceptional scenario with regard to drug targeting, as oral administration has the potential to deliver the drug directly to the site(s) of action. Consequently, retention of the drug within the intestinal lumen and tissue, rather than systemic absorption, is frequently desirable. AREAS COVERED In this article, the traditional drug-delivery strategies used in IBD are briefly summarized. These include rectal dosage forms and oral systems that target the lower intestine/colon by pH-, time-, microflora-, and pressure-dependent mechanisms. Then, the article offers an updated overview of recently developed delivery systems aimed to achieve maximal drug concentrations in the inflamed intestinal tissues with minimal systemic side effects. These include antibodies, small molecules, Janus kinase inhibitors, particulate carrier systems, anti-inflammatory peptides, gene therapy, and transgenic bacteria. The various approaches are reviewed, and the challenges that still remain to be overcome are discussed. EXPERT OPINION The molecular revolution of the past decade profoundly influenced the treatment and management of IBD. In the coming years, this trend is expected to continue. Yet, many challenges are still ahead. A strong collaborative effort by experts from different fields is encouraged and necessary to maximize our success in IBD drug targeting.
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Affiliation(s)
- Omri Wolk
- Ben-Gurion University of the Negev, School of Pharmacy, Faculty of Health Sciences, Department of Clinical Pharmacology, Beer-Sheva, Israel
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Mora D, Barba P, Ruiz I, Castillo N, Aizpurua M, Roselló E, Bosch F, Valcárcel D. Primary gastrointestinal aspergillosis 6 months after allogeneic hematopoietic cell transplantation: a case report. Transpl Infect Dis 2013; 15:E107-10. [DOI: 10.1111/tid.12082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 12/30/2012] [Accepted: 01/16/2013] [Indexed: 12/01/2022]
Affiliation(s)
- D. Mora
- Department of Hematology; Vall d'Hebron Hospital; Barcelona; Spain
| | - P. Barba
- Department of Hematology; Vall d'Hebron Hospital; Barcelona; Spain
| | - I. Ruiz
- Department of Infectious Diseases; Vall d'Hebron Hospital; Barcelona; Spain
| | - N. Castillo
- Department of Hematology; Vall d'Hebron Hospital; Barcelona; Spain
| | - M. Aizpurua
- Department of Pathology; Vall d'Hebron Hospital; Barcelona; Spain
| | - E. Roselló
- Department of Microbiology; Vall d'Hebron Hospital; Barcelona; Spain
| | - F. Bosch
- Department of Hematology; Vall d'Hebron Hospital; Barcelona; Spain
| | - D. Valcárcel
- Department of Hematology; Vall d'Hebron Hospital; Barcelona; Spain
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5
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Suzuki Y, Motoya S, Takazoe M, Kosaka T, Date M, Nii M, Hibi T. Efficacy and tolerability of oral budesonide in Japanese patients with active Crohn's disease: a multicentre, double-blind, randomized, parallel-group Phase II study. J Crohns Colitis 2013; 7:239-47. [PMID: 22766525 DOI: 10.1016/j.crohns.2012.06.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 06/08/2012] [Accepted: 06/08/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Current treatments for Japanese patients with active Crohn's disease have not proved optimal, and new treatment options are required. The present study therefore evaluated the efficacy and tolerability of oral budesonide in Japanese patients with mild-to-moderate active Crohn's disease. METHODS In this multicentre, double-blind, randomized, parallel-group, Phase II study, patients (18-65 years) with baseline Crohn's Disease Activity Index (CDAI) score≥200 were randomized to once-daily (od) oral budesonide 9 mg or 15 mg, or matching placebo, for 8 weeks. Concomitant therapy with sulfasalazine or 5-aminosalicylic acid, and nutritional therapy, was allowed. The rate of remission (defined as CDAI score≤150) after 8 weeks' treatment (primary variable), health-related quality of life (assessed using the Inflammatory Bowel Disease Questionnaire [IBDQ]), and tolerability were assessed. RESULTS 77 patients were randomized and 63 completed the study. The proportion of budesonide-treated patients with remission after 8 weeks' treatment was higher compared with placebo (23.1%, 28.0%, and 11.5% for budesonide 9 mg, 15 mg, and placebo, respectively; no significant difference). The mean change from baseline to week 8 in CDAI total score (-48.0, -58.2, and -27.2, respectively) and IBDQ total score (10.8, 23.2, and 6.5, respectively) was greater for budesonide-treated patients than placebo recipients. While budesonide 9 mg and 15 mg demonstrated similar efficacy, budesonide 9 mg caused fewer drug- and glucocorticosteroid-related adverse events and less adrenal suppression. CONCLUSIONS Oral budesonide 9 mg od (for up to 8 weeks) may offer a new treatment option for Japanese patients with mild-to-moderate active Crohn's disease.
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Affiliation(s)
- Yasuo Suzuki
- Sakura Medical Center, Toho University, Chiba, Japan
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El Fakih R, Obi GA, Scholoff A, Carrum G, Kamble RT. Systemic effects of oral budesonide in hematopoietic transplant: implications of drug interaction with azoles. Bone Marrow Transplant 2012; 47:1370-1. [PMID: 22327133 DOI: 10.1038/bmt.2012.17] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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7
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Pithadia AB, Jain S. Treatment of inflammatory bowel disease (IBD). Pharmacol Rep 2011; 63:629-42. [PMID: 21857074 DOI: 10.1016/s1734-1140(11)70575-8] [Citation(s) in RCA: 242] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 11/18/2010] [Indexed: 02/06/2023]
Abstract
Inflammatory bowel disease (IBD) is a chronic inflammatory disease of the gastrointestinal tract, which includes Crohn's disease (CD) and ulcerative colitis (UC). These diseases have become important health problems. Medical therapy for IBD has advanced dramatically in the last decade with the introduction of targeted biologic therapies, the optimization of older therapies, including rugs such as immunomodulators and 5-aminosalicylic acid (5-ASA), and a better understanding of the mucosal immune system and the genetics involved in the pathogenesis of IBD. The goal of IBD therapy is to induce and maintain remission. The current treatment paradigm involves a step-up approach, moving to aggressive, powerful therapies only when milder therapies with fewer potential side effects fail or when patients declare themselves to have an aggressive disease. This review focuses on the current treatments for inflammatory bowel disease.
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Affiliation(s)
- Anand B Pithadia
- Department of Pharmacology, L.M. College of Pharmacy, Navrangpura, Ahmedabad-3800 09 Gujarat, India.
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8
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Turner Z, Lanford L, Webber S. Oral budesonide as a therapy for protein-losing enteropathy in patients having undergone Fontan palliation. CONGENIT HEART DIS 2011; 7:24-30. [PMID: 22129195 DOI: 10.1111/j.1747-0803.2011.00593.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Protein-losing enteropathy is associated with Fontan palliation for single-ventricle physiology and has been difficult to treat. Limited data suggest the successful use of oral budesonide (Entocort, AstraZeneca) as a palliative measure. METHODS We examine our single-institution retrospective experience in eight patients who were treated with this therapy. RESULTS Median pretherapy albumin level was 1.7 g/dL (range 1.0-2.7 g/dL), 3 months after therapy was 3.1 g/dL (range 2-4.8 g/dL), and by the end of the first year was 3.4 g/dL (range 2.1-5.3 g/dL). All patients had at least a transient improvement, and at latest follow-up (median 29 months, range 3-51 months) five patients remain on therapy. Five of eight patients had required pretherapy albumin transfusions; one patient required albumin infusions after therapy. Four patients had side effects associated with the medication. CONCLUSIONS Oral budesonide is an additional therapy that has the potential to improve symptoms and delay need for heart transplantation in this patient population.
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Affiliation(s)
- Zachary Turner
- Heart Center, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Ave., Pittsburgh, PA 15224, USA
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9
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Silverman J, Otley A. Budesonide in the treatment of inflammatory bowel disease. Expert Rev Clin Immunol 2011; 7:419-28. [PMID: 21790284 DOI: 10.1586/eci.11.34] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Inflammatory bowel disease, including Crohn's disease and ulcerative colitis, features recurrent episodes of inflammation of the GI tract. The treatment of inflammatory bowel disease is aimed at breaking the cycle of relapsing and remitting inflammation by inducing and maintaining remission. Systemically active conventional corticosteroids have long played a role in the induction of remission in both Crohn's disease and ulcerative colitis, however, their long-term use can lead to adverse systemic effects. Budesonide, a synthetic steroid, has potent local anti-inflammatory effects and limited systemic bioavailability making it an appealing therapeutic option. Ulcerative colitis with predominantly distal disease may be treated with topical budesonide, however, novel oral controlled-release formulations have also been developed to allow for treatment of the entire colon. This article summarizes the use of budesonide in the management of inflammatory bowel disease.
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Affiliation(s)
- Jason Silverman
- Department of Pediatrics, Dalhousie University and IWK Health Centre, Halifax, NS, Canada
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10
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Dahan A, Amidon GL, Zimmermann EM. Drug targeting strategies for the treatment of inflammatory bowel disease: a mechanistic update. Expert Rev Clin Immunol 2010; 6:543-50. [PMID: 20594127 DOI: 10.1586/eci.10.30] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The therapeutic management of inflammatory bowel disease (IBD) represents the perfect scenario for drug targeting to the site(s) of action. While existing formulation-based targeting strategies include rectal dosage forms and oral systems that target the colon by pH-, time-, microflora- and pressure-triggered drug release, novel approaches for site-specific delivery in IBD therapy will target the inflamed intestine per se rather than intestinal region. The purpose of this article is to present a mechanistic update on the strategies employed to achieve minimal systemic exposure accompanied by maximal drug levels in the inflamed intestinal tissue. The introduction of biological agents, micro/nanoparticulate carriers including liposomes, transgenic bacteria, and gene therapy opportunities are discussed, as well as the challenges remaining to be achieved in the targeted treatment of IBD.
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Affiliation(s)
- Arik Dahan
- Department of Clinical Pharmacology, School of Pharmacy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel.
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11
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Seow CH, Benchimol EI, Steinhart AH, Griffiths AM, Otley AR. Budesonide for Crohn's disease. Expert Opin Drug Metab Toxicol 2009; 5:971-9. [DOI: 10.1517/17425250903124355] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Ibrahim RB, Abidi MH, Cronin SM, Lum LG, Al-Kadhimi Z, Ratanatharathorn V, Uberti JP. Nonabsorbable corticosteroids use in the treatment of gastrointestinal graft-versus-host disease. Biol Blood Marrow Transplant 2009; 15:395-405. [PMID: 19285626 DOI: 10.1016/j.bbmt.2008.12.487] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Accepted: 12/04/2008] [Indexed: 02/05/2023]
Abstract
For over a decade, nonabsorbable corticosteroids have been employed in the treatment of gastrointestinal graft-versus-host-disease (GVHD) in hematopoietic stem cell transplant (HSCT), as monotherapy or in combination with systemic corticosteroids. The majority of the evidence showing a favorable outcome consisted of case series, small phase II trials and a large randomized phase III trial. The 2 most commonly studied molecules were oral budesonide and beclomethasone diproprionate. Although these reports hint at some benefit with the local treatment strategy, their methodologic inconsistencies preclude meaningful adoption to everyday clinical practice. This review evaluates the current evidence of nonabsorbable corticosteroids in HSCT and sets forth recommendations for future trials with these agents.
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Affiliation(s)
- Rami B Ibrahim
- Karmanos Cancer Institute and Wayne State University, Detroit, Michigan 48201, USA.
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Latli B, Krishnamurthy D, Senanayake C. Synthesis of tritium- and deuterium-labeled budesonide. J Labelled Comp Radiopharm 2008. [DOI: 10.1002/jlcr.1480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Maier A, Zimmermann C, Beglinger C, Drewe J, Gutmann H. Effects of budesonide on P-glycoprotein expression in intestinal cell lines. Br J Pharmacol 2006; 150:361-8. [PMID: 17179942 PMCID: PMC2013900 DOI: 10.1038/sj.bjp.0706992] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND AND PURPOSE P-glycoprotein (P-gp) is an important efflux transporter that supports the barrier function of the gut against invading antigens and against administered drugs. Since glucocorticoids, such as budesonide, are frequently used during inflammatory bowel disease we investigated how budesonide influences P-gp expression in different intestinal cell lines. EXPERIMENTAL APPROACH LS180 and Caco-2 cells were incubated with budesonide and changes in P-gp expression were determined on mRNA, protein and functional level. The mRNA expression levels of glucocorticoid receptor (GR) and pregnane X receptor (PXR) were determined in these cell lines. PXR receptor was transiently transfected into Caco-2 cells. KEY RESULTS Budesonide showed an induction of P-gp in LS180 cells and a down-regulation in Caco-2 cells. Expression levels of nuclear receptors revealed high expression of PXR only in LS180 cells and exclusive expression of GR in Caco-2 cells. Mifepristone, an anti-glucocorticoid, could not reverse the down-regulation of P-gp by budesonide in Caco-2 cells. In PXR-transfected Caco-2 cells the budesonide-mediated down-regulation of P-gp was abolished. Furthermore the expression of cytochrome P450 3A4 (CYP3A4), another PXR target gene, was induced in PXR-transfected Caco-2 cells after budesonide treatment. CONCLUSIONS AND IMPLICATIONS Budesonide has the potential to influence MDR1 expression in vitro. In LS180 cells, the induction of MDR1 by budesonide probably is mediated via PXR. The mechanism of the down-regulation in Caco-2 cells still remains unclear, but GR does not seem to be involved. Further studies are required to evaluate how budesonide alters P-gp expression in vivo.
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Affiliation(s)
- A Maier
- Department of Clinical Pharmacology and Toxicology, University Hospital Basel Basel, Switzerland
| | - C Zimmermann
- Department of Clinical Pharmacology and Toxicology, University Hospital Basel Basel, Switzerland
| | - C Beglinger
- Department of Internal Medicine, Division of Gastroenterology, University Hospital of Basel Basel, Switzerland
| | - J Drewe
- Department of Clinical Pharmacology and Toxicology, University Hospital Basel Basel, Switzerland
- Author for correspondence:
| | - H Gutmann
- Department of Clinical Pharmacology and Toxicology, University Hospital Basel Basel, Switzerland
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Brunner M, Ziegler S, Di Stefano AFD, Dehghanyar P, Kletter K, Tschurlovits M, Villa R, Bozzella R, Celasco G, Moro L, Rusca A, Dudczak R, Müller M. Gastrointestinal transit, release and plasma pharmacokinetics of a new oral budesonide formulation. Br J Clin Pharmacol 2006; 61:31-8. [PMID: 16390349 PMCID: PMC1884991 DOI: 10.1111/j.1365-2125.2005.02517.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
AIMS The aims of the study were to: (1) evaluate the gastrointestinal transit, release and absorption of budesonide from tablets with a new multimatrix formulation (MMX) designed to release the drug throughout the whole colon, and (2) assess the influence of food on budesonide bioavailability. METHODS Two phase I studies, each comprising 12 healthy males, were performed. Gastrointestinal transit of (153)Sm-labelled tablets containing 9 mg budesonide was evaluated by means of pharmaco-scintigraphy. The effect of food was tested by comparing plasma pharmacokinetics after intake of a high fat and high calorie breakfast with fasting controls. RESULTS (153)Sm-labelled tablets reached the ascending colon after a mean +/- SD 9.8 +/- 6.9 h. Initial tablet disintegration was observed in the ileum in 42% and the ascending and transverse colon in 33% of subjects. Ninety-six per cent of the dose was absorbed into the systemic circulation during passage through the whole colon including the sigmoid. Food significantly decreased C(max) values from 1429 +/- 1014 to 1040 +/- 601 pg mL(-1) (P = 0.028) and AUC values from 14 814 +/- 11 254 to 13 486 +/- 9369 pg h(-1) mL(-1) (P = 0.008). Mean residence time and t(max) increased by 12-29%. There was no drug accumulation after 1 week of once daily oral administration of budesomide. CONCLUSIONS MMX-budesonide tablets appear suitable for targeted colonic drug delivery. Transit parameters and low systemic bioavailability warrant further studies with the new formulation.
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Affiliation(s)
- M Brunner
- Department of Clinical Pharmacology, Division of Clinical Pharmacokinetics, Medical University of Vienna, Vienna, Austria.
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Annese V, Latiano A, Rossi L, Lombardi G, Dallapiccola B, Serafini S, Damonte G, Andriulli A, Magnani M. Erythrocytes-mediated delivery of dexamethasone in steroid-dependent IBD patients-a pilot uncontrolled study. Am J Gastroenterol 2005; 100:1370-5. [PMID: 15929772 DOI: 10.1111/j.1572-0241.2005.41412.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Autologous erythrocytes can be used as carriers of drugs, owing to the ability of their membrane to be opened and resealed under appropriate conditions. In this pilot uncontrolled study, we investigated efficacy and safety of dexamethasone-encapsulated erythrocytes in steroid-dependent IBD patients. MATERIALS AND METHODS Ten patients (5 with ulcerative colitis and 5 with Crohn's disease) with steroid dependency ranging from 8 to 60 months were studied. Seven of them were in clinical remission, and the remaining three had mild activity. Eight patients were also under azathioprine or 6-MP for at least 6 months (range 6-24 months), while another two patients were intolerant to both drugs. Fifty milliliters of blood were drawn from each subject; dexamethasone 21-Phosphate (Dex 21-P) was encapsulated into erythrocytes by means of specially designed equipment, and drug-loaded erythrocytes were infused into original donors. The procedure was repeated after 4 and 8 wk, and patients were instructed to withdraw corticosteroids. RESULTS A mean dose of 5.5+/-2.4 mg Dex 21-P was loaded in the erythrocytes at each treatment. Following re-infusion of loaded erythrocytes, plasma Dexamethasone (Dex) concentrations were detected after as long as 28 days. Steroids were completely withdrawn by the second month. After the third infusion, all patients, including the three with mild active disease, were in clinical remission. ESR levels dropped from 47+/-27 at baseline to 27+/-16 mm/h (p<0.02), and CRP levels from 1.6+/-1.3 to 0.6+/-0.5 mg/dl (p<0.02). After a mean follow-up of 12+/-3 months, six patients relapsed, and the remaining four patients remained in remission. Pre-existing steroid-related adverse effects disappeared during the follow-up. CONCLUSIONS Loading of Dex 21-P in autologous erythrocytes is feasible and safe. The very low dose of Dex released in blood stream was able to maintain patients in clinical remission and allowed steroids withdrawal.
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Affiliation(s)
- Vito Annese
- Dipartimento di Medicina Generale e Specialistica, Unità di Gastroenterologia, Ospedale Casa Sollievo della Sofferenza, I.R.C.C.S., San Giovanni Rotondo, Italy
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Kesisoglou F, Zimmermann EM. Novel drug delivery strategies for the treatment of inflammatory bowel disease. Expert Opin Drug Deliv 2005; 2:451-63. [PMID: 16296767 DOI: 10.1517/17425247.2.3.451] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Inflammatory bowel disease (IBD) encompasses two idiopathic inflammatory diseases of the intestinal tract: Crohn's disease and ulcerative colitis. Existing therapy for IBD consists mainly of orally or rectally administered small drug molecules, such as 5-aminosalicylates and corticosteroids, or potent systemic immune suppressants. IBD presents a challenging target for drug delivery, particularly by the oral route, as, contrary to most therapeutic regimens, minimal systemic absorption and maximal intestinal wall drug levels are desired. Several delivery strategies are employed to achieve this goal, including the chemical modification of the drug molecules, the use of controlled- and delayed-release formulations and the use of bioadhesive particles. The goal of this review is to summarise existing IBD therapy and examine novel approaches in intestinal drug delivery.
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Affiliation(s)
- Filippos Kesisoglou
- University of Michigan Department of Pharmaceutical Sciences, College of Pharmacy, Ann Arbor, MI 48109-1065, USA
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Dilger K, Schwab M, Fromm MF. Identification of budesonide and prednisone as substrates of the intestinal drug efflux pump P-glycoprotein. Inflamm Bowel Dis 2004; 10:578-83. [PMID: 15472518 DOI: 10.1097/00054725-200409000-00012] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Steroid resistance is a major problem in the management of patients with inflammatory bowel disease. In Crohn disease, poor response to corticosteroids has been related to increased expression of the drug efflux pump, P-glycoprotein. However, it has not been investigated thoroughly whether corticosteroids commonly used for drug therapy in inflammatory bowel disease are substrates of P-glycoprotein. We tested the hypothesis that budesonide and prednisone are substrates of P-glycoprotein thereby possibly contributing to variable therapeutic effects. Polarized, basal to apical transport of [3H]budesonide and [3H]prednisone was studied in monolayers of L-MDR1 cells (LLC-PK1 cells stably transfected with human MDR1 cDNA) and Caco-2 cells, both of which express P-glycoprotein in their apical membrane. Drug transport was measured during 4 hours at substrate concentrations of 5 microM. Net transport rates and permeability coefficients were calculated. Inhibition of P-glycoprotein-mediated transport across Caco-2 monolayers was determined after addition of the P-glycoprotein inhibitor PSC-833. The net transport rate from the basolateral to the apical side was significantly higher in L-MDR1 than in LLC-PK1 cells for both budesonide and prednisone. Apparent permeability coefficients of budesonide and prednisone reflected polarized transport from basal to apical. PSC-833 inhibited the polarized transport of both corticosteroids. In conclusion, budesonide and prednisone were identified as substrates of the intestinal drug efflux pump, P-glycoprotein. Therefore, drug secretion via P-glyco-protein into gut lumen might play a more important role in pharmacokinetics and pharmacodynamics of these corticosteroids than currently appreciated in gastroenterological practice.
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