The clinical significance of food-drug interactions: a review

Predictive models for drugs exhibiting negative food effects based on their biopharmaceutical characteristics

CONTEXT

A drug is defined to exhibit food effects if its pharmacokinetic parameter, area under the curve (AUC₀₋∞) is different when co-administered with food in comparison with its administration on a fasted stomach. Food effects of drugs administered in immediate release dosage forms were classified as positive, negative, and no food effects.

OBJECTIVE

In this study, predictive models for negative food effects of drugs that are stable in the gastrointestinal tract and do not complex with Ca²⁺ are reported.

METHODS

An empirical model was developed using five drugs exhibiting negative food effects and seven drugs exhibiting no food effects by multiple regression analysis, based on biopharmaceutical properties generated from in vitro experiments. An oral absorption model was adopted for simulating negative food effects of model compounds using in situ rat intestinal permeability.

RESULTS

Analysis of selected model drugs indicated that percent food effects correlated to their dissociation constant, K (K(a) or K(b)) and Caco-2 permeabilities. The obtained predictive equation was: Food effect (%)=(2.60 x 10⁵·P(app))--(2.91 x 10⁵·K)--8.50. Applying the oral absorption model, the predicted food effects matched the trends of published negative food effects when the two experimental pH conditions of fed and fasted state intestinal environment were used.

CONCLUSION

A predictive model for negative food effects based on the correlation of food effects with dissociation constant and Caco-2 permeability was established and simulations of food effects using rat intestinal permeability supported the drugs? published negative food effects. Thus, an empirical and a mechanistic model as potential tools for predicting negative food effects are reported.

In vitro food-drug interaction study: Which milk component has a decreasing effect on the bioavailability of ciprofloxacin?

The purpose of the present work was developing an in vitro dissolution test to highlight the possible molecular background causing ciprofloxacin (CPFX)-milk interaction. The in vitro dissolution of CPFX from film-coated tablets (Ciprinol) 500mg) was examined at different pH values, simulating certain parts of the gastrointestinal tract, in the presence of water, low-fat milk, casein- or calcium enriched water. In order to determine the amount of dissolved CPFX, solid phase extraction sample preparation followed by high performance liquid chromatography coupled with mass spectrometry was applied. Comparing the dissolution efficiency values in various media, it can be concluded, that casein has a more pronounced effect on the absorbable amount of the antibiotic at each pH value studied, than calcium. In the case of concomitant intake of CPFX film-coated tablet and milk or other dairy products not only the complexation with calcium, but also the adsorption of CPFX on the surface of proteins decreases the absorbable amount of CPFX.

Influence of food on the oral bioavailability of deramciclane from film-coated tablet in healthy male volunteers

The effect of a high-fat meal on the oral bioavailability of deramciclane 30 mg tablet was evaluated in 18 healthy male volunteers in a randomised, single dose, two-way crossover study. The drug was administered following an overnight fast or a standardised high-fat breakfast. The plasma concentrations of deramciclane and N-desmethylderamciclane were determined by using a validated HPLC-MS -MS/MS method. An effect of food on the bioavailability was indicated if the 90% confidence interval (CI) for the ratio of geometric means of fed and fasted treatments was not contained in the equivalence limit of 0.8-1.25 for AUC and C(max). The ratios of the mean C(max) and AUC(0-infinity) values of deramciclane were 1.24 (90% CI 1.12-1.38) and 1.31 (90% CI 1.21-1.41) in fed versus fasted subjects, which overlapped but exceeded the equivalence limit. In contrast to the parent compound, the 90% CI of the mean ratios for AUC(0-infinity) and C(max) of N-desmethylderamciclane were within the predefined range. The 24 and 31% increase in C(max) and AUC(0-infinity) of deramciclane, respectively, under fed condition is modest and probably has no clinical significance since it is relatively small compared to the inter-individual variability of these parameters.

Bicalutamide

Bicalutamide is a nonsteroidal pure antiandrogen given at a dosage of 150 mg once daily as monotherapy for the treatment of early (localised or locally advanced) nonmetastatic prostate cancer. It is used at a dosage of 50 mg once daily in combination with a luteinising hormone-releasing hormone analogue or surgical castration for the treatment of advanced prostate cancer. Bicalutamide is a racemate and its antiandrogenic activity resides almost exclusively in the (R)-enantiomer, with little, if any, activity in the (S)-enantiomer. (R)-Bicalutamide is slowly and saturably absorbed, but absorption is unaffected by food. It has a long plasma elimination half-life (1 week) and accumulates about 10-fold in plasma during daily administration. (S)-Bicalutamide is much more rapidly absorbed and cleared from plasma; steady-state concentrations (Css) of (R)-bicalutamide are 100-fold higher than those of (S)-bicalutamide. Css increases linearly with doses up to 50 mg, but nonlinearly at higher doses, reaching a plateau above 300 mg. Css is higher in Japanese than in Caucasians, but no relationship with degree of renal impairment, bodyweight or age exists. Although mild-to-moderate hepatic impairment does not affect pharmacokinetics, there is evidence for slower elimination of (R)-bicalutamide in subjects with severe hepatic impairment. Bicalutamide metabolites are excreted almost equally in urine and faeces with little or no unchanged drug excreted in urine; conversely, unchanged drug predominates in plasma. Bicalutamide in faeces is thought to arise from hydrolysis of bicalutamide glucuronide and from unabsorbed drug. Bicalutamide appears to be cleared almost exclusively by metabolism; this is largely mediated by cytochrome P450 (CYP) for (R)-bicalutamide, but glucuronidation is the predominant metabolic route for (S)-bicalutamide. (S)-Bicalutamide is metabolised in vitro by CYP3A4, and it is probable that this isoenzyme is also responsible for the metabolism of (R)-bicalutamide. In vitro data suggest that (R)-bicalutamide has the potential to inhibit CYP3A4 and, to a lesser extent, CYP2C9, 2C19 and 2D6. However, using midazolam as a specific CYP3A4 marker, no clinically relevant inhibition is observed in vivo with bicalutamide 150mg. Although bicalutamide is a CYP inducer in laboratory animals, dosages < or = 150 mg/day have shown no evidence of enzyme induction in humans. Daily administration of bicalutamide increases circulating levels of gonadotrophins and sex hormones; although testosterone increases by up to 80%, concentrations in most patients remain within the normal range. Bicalutamide produces a dose-related decrease in prostate-specific antigen (PSA) at dosages < or = 150 mg/day. However, little relationship is observed between median PSA reduction and (R)-bicalutamide Css.

Effect of food on the pharmacokinetics of ropinirole in parkinsonian patients

AIMS

Ropinirole is a specific non-ergoline dopamine D2-receptor agonist with antiparkinsonian properties. The pharmacokinetic parameters of ropinirole taken in the fasted condition were compared with those when it was co-administered with food.

METHODS

This was an open, randomized, two sessions cross over study in 12 patients with Parkinson's disease, comparing the steady-state pharmacokinetic profiles of ropinirole on two different study days: 'fasted' and 'fed'.

RESULTS

The mean Cmax was lower in the 'fed' regimen than in the 'fasted' one (-25%, P=0.002). The median tmax was observed 2.6 h later in the 'fed' regimen than in the 'fasted' regimen (P<0.05). There was a slight but significant decrease in AUC(0,8 h) in the 'fed' regimen (P=0.03).

CONCLUSIONS

Food decreases the rate of absorption of ropinirole, but has little effect on the extent of absorption.

Effect of time interval between food and drug ingestion on the absorption of oxybutynin from a controlled-release tablet

The effect of time interval between food and drug ingestion on the bioavailability of oxybutynin was investigated in a randomized, three-phase cross-over study in 31 healthy volunteers. The serum concentrations of oxybutynin and the metabolite, N-desethyloxybutynin were measured up to 48 hr after ingestion of a controlled-release 10 mg oxybutynin tablet either in fasting state, 2 hr after breakfast or 1 hr before. The Cmax of both oxybutynin (P < 0.0001) and N-desethyloxybutynin (P < 0.0001) and the AUC0-1 of N-desethyloxybutynin (P < 0.05) were significantly larger when oxybutynin was ingested 2 hr after breakfast, than during the fasting, but the AUC0-1 of oxybutynin remained unchanged. Breakfast ingested 1 hr after oxybutynin did not affect the pharmacokinetic parameters of oxybutynin or N-desethyloxybutynin. The saliva secretion rate decreased slightly more (P < 0.05), when oxybutynin was administered 2 hr after breakfast than during fasting. The effect of food ingestion on the serum concentrations of oxybutynin and N-desethyloxybutynin is expected to have minor clinical significance only. However, ingestion of the controlled-release tablet 1 hr before meal increases the likelihood of obtaining constant drug levels with lower peak concentrations during the dosage interval, and thus ingestion of the controlled-release tablet 0.5-1 hr before food may well improve tolerability and compliance in patients who suffer from adverse reactions.

Effects of milk and food on the absorption of enoxacin

The effects of milk and a standard breakfast on the oral absorption of enoxacin were evaluated in eight healthy volunteers in a randomized, balanced, four-way crossover study. After an overnight fast, 400 mg enoxacin was given with water, milk, a breakfast or with a breakfast and milk. The extent of enoxacin absorption was not affected by any of the three treatments, and no statistically significant changes were found with respect to peak plasma enoxacin concentration or time to peak. We conclude that enoxacin can be taken together with food and dairy products.

Absorption and in vivo dissolution of hydroxycholoroquine in fed subjects assessed using deconvolution techniques

1. Nine healthy subjects each received three doses of 155 mg rac-hydroxychloroquine, as a tablet, an oral solution and by intravenous infusion, in a randomised cross-over design study, 30 min after a standard high fat breakfast. 2. Four methods of deconvolution were used to assess the absolute bioavailability of the tablet and oral solution doses. These were the delta function method, the staircase approximation method, and two least squares methods using a single first-order input and a sequential first-order input. The mean (+/- s.d.) fraction absorbed estimated by the four methods was 0.64 +/- 0.14 after the tablet and 0.87 +/- 0.30 after the oral solution. Wide intersubject variability was observed (0.50-0.91 for the tablet; 0.30-1.37 for the solution). 3. The mean (+/- s.d.) absorption half-life was 3.7 +/- 2.0 h for the tablet and 3.3 +/- 1.6 h for the solution, suggesting that absorption following the tablet dose was not rate-limited by dissolution. 4. The in vivo dissolution rate, extent of release and lag-time were determined using cube-root law and first-order input functions. Dissolution was found to be rapid, after a significant lag-time, but incomplete in some subjects. 5. The rate and extent of absorption was similar to that reported previously for fasted subjects. The lag-time before absorption commenced in fed subjects (1.65 +/- 0.46 h) showed a significant three-fold increase over that reported previously in fasting subjects (0.63 +/- 0.33 h), but this difference is not likely to be of clinical significance.

Milk and yoghurt do not impair the absorption of ofloxacin

The effects of milk and yoghurt on the oral absorption of ofloxacin were studied in seven healthy volunteers in a randomized cross-over trial. After an overnight fast, 200 mg ofloxacin was given with 300 ml water, milk or yoghurt. Plasma concentrations and urinary excretion of ofloxacin were determined up to 24 h. Values of total plasma AUC and 24 h urinary excretion of ofloxacin were not affected by milk or yoghurt. Plasma ofloxacin concentrations from 0.5 to 1.5 h and the peak concentration were lower (P less than 0.05) after yoghurt than without and the time to peak was prolonged by 1 h (P less than 0.05).

Inhibition of norfloxacin absorption by dairy products

Seven healthy subjects received, after an overnight fast, a single 200-mg oral dose of norfloxacin with water, whole milk, and unflavored yoghurt. Coadministration of milk or yoghurt reduced the extent of norfloxacin absorption and the mean peak concentration in plasma by approximately 50%. Taking of norfloxacin with these liquid dairy products should be avoided.