Lack of effect of ezogabine/retigabine on the pharmacokinetics of digoxin in healthy individuals: results from a drug-drug interaction study

Introduction

The potential for ezogabine/retigabine (EZG/RTG) and its N-acetyl metabolite (NAMR) to inhibit the transporter protein P-glycoprotein-(P-gp)-mediated digoxin transport was tested in vitro. EZG/RTG did not inhibit P-gp. However, NAMR inhibited P-gp in a concentration-dependent manner. Based on these in vitro results, NAMR had the potential to inhibit P-gp at therapeutic doses of EZG/RTG (600–1,200 mg/day). As digoxin has a narrow therapeutic index, inhibition of digoxin clearance may have an impact on its safety.

Methods

An open-label, single-center, two session, fixed-sequence study was conducted to assess the effect of co-administration of therapeutic doses of EZG/RTG on digoxin pharmacokinetics in healthy adults. In session 1, subjects received a single dose of digoxin 0.25 mg. In session 2, EZG/RTG was up-titrated over 6 weeks. Digoxin 0.25 mg was co-administered at EZG/RTG steady-state doses of 600, 900, and, based on tolerability, 1,050/1,200 mg/day. Blood samples were collected over 144 hours for determination of digoxin, EZG/RTG, and NAMR concentrations. Urine samples were collected over 48 hours for determination of digoxin concentrations.

Results

Of 30 subjects enrolled, 29 were included in the pharmacokinetic analysis. Compared with digoxin alone, co-administration with EZG/RTG led to small increases in the digoxin plasma area under the concentration–time curve (AUC)_0–120 at doses of 600, 900, and 1,050/1,200 mg (geometric mean ratio 1.08, 90% confidence interval [CI] 1.01–1.15; 1.18, 90% CI 1.10–1.27; 1.13, 90% CI 1.05–1.21, respectively). Safety was consistent with previous repeat-dose studies of EZG/RTG in healthy subjects.

Conclusion

Co-administration of EZG/RTG across the therapeutic range resulted in small, non-dose-dependent and non-clinically relevant increases in digoxin systemic exposure, suggesting that digoxin dose adjustment is not necessary.

Clinical pharmacokinetics of retigabine/ezogabine

BACKGROUND

Retigabine is an antiepileptic drug that reduces neuronal excitability by enhancing potassium channel activity.

METHODS

This manuscript summarizes the pharmacokinetic and biopharmaceutical properties of retigabine collated from published and unpublished in vitro and clinical phase I-III studies in healthy volunteers or patients with partial-onset seizures.

RESULTS

Retigabine is rapidly absorbed with a median time to C(max) of 0.5-2.0 hours. Thereafter, plasma concentrations decline in a mono-exponential manner, with a median half-life of 6-8 hours. The absolute oral bioavailability of retigabine is ~60%. Retigabine is metabolized extensively by N-acetylation and subsequent N-glucuronidation. In vitro and in vivo studies have shown that the drug-interaction potential of retigabine is low. The pharmacokinetics of retigabine are linear over the dose range 200-400mg three times daily (tid), with ~ 35-50% between-subject variability. Systemic exposure was not affected by a high fat meal, but C(max) was, ~14% and ~38% higher in the fed versus fasted state for the 200 and 400mg tablets, respectively. Retigabine drug-related material is primarily eliminated renally with unchanged retigabine accounting for ~36%. Retigabine plasma clearance decreased as severity of renal or hepatic impairment increased. Systemic exposure to retigabine is unaffected by gender when normalized for body weight. In elderly patients, retigabine systemic exposure was higher, and half-life was longer than in younger patients.

CONCLUSIONS

Retigabine should be administered tid without regard to food. No adjustments required for gender, race, or genetic/polymorphisms. Dosage adjustments are recommended in elderly patients and those with moderate and severe renal or moderate hepatic impairment.

Efficacy and tolerability exposure-response relationship of retigabine (ezogabine) immediate-release tablets in patients with partial-onset seizures

BACKGROUND

Retigabine (international nonproprietary name)/ezogabine (United States adopted name) is an antiepileptic drug (AED) that enhances KCNQ (Kv7) potassium channel activity.

OBJECTIVES

The aim of this study was to explore the relationship between retigabine/ezogabine systemic exposure and efficacy and adverse events (AEs) of retigabine/ezogabine from Phase III clinical trials.

METHODS

Data were combined from Studies 301 and 302, which were both randomized, double-blind, placebo-controlled, multicenter, parallel-group studies with similar inclusion and exclusion criteria. All patients had partial-onset seizures and were receiving 1 to 3 concomitant AEDs. Systemic exposure was predicted for each patient as the average steady-state AUC0-τ during the 12-week maintenance phase, based on a population pharmacokinetic model developed for retigabine/ezogabine. Efficacy end points included reduction in total partial-seizure frequency from baseline and probability of ≥50% reduction from baseline in seizure frequency. The probabilities of occurrence of 6 AEs were also evaluated.

RESULTS

AUC0-τ values increased linearly over the 600- to 1200-mg/d dose range. Over the entire AUC0-τ range, the probability of efficacy was greater than that for any AE. The slopes of the exposure-response relationship for probability of dizziness and abnormal coordination were similar to that for efficacy, whereas the slopes for dysarthria, somnolence, tremor, and blurred vision were shallower, indicating that the probability of these events occurring was less affected than the probability of efficacy by increases in retigabine/ezogabine AUC0-τ.

CONCLUSIONS

Based on the summary statistics of pharmacokinetic parameters, systemic exposure to retigabine/ezogabine increased linearly with dose (600-1200 mg/d). Population pharmacokinetics and pharmacodynamics showed that the probability of efficacy and AEs increased with increasing systemic retigabine/ezogabine exposure, and the probability of efficacy was higher than the probability of any of the AEs. The 35%-50% between-patient variability and overlap between retigabine/ezogabine dose levels in AUC0-τ values indicate that, as with other AEDs, doses should be individually titrated based on a balance between efficacy and tolerability.

Pharmacokinetics of azithromycin and moxifloxacin in human conjunctiva and aqueous humor during and after the approved dosing regimens

PURPOSE

To evaluate the ocular pharmacokinetics of azithromycin and moxifloxacin in human conjunctiva and aqueous humor in subjects undergoing cataract surgery.

DESIGN

Multicenter, open-label, randomized study.

METHODS

Subjects scheduled for routine cataract surgery and with normal-appearing conjunctiva were eligible. One conjunctival biopsy sample and 1 aqueous humor sample were obtained from subjects randomly assigned to 1 of 10 prespecified time points (1 to 312 hours) after treatment initiation of azithromycin ophthalmic solution 1% or moxifloxacin ophthalmic solution 0.5%. Samples were assayed using liquid chromatography tandem mass spectrometry.

RESULTS

Azithromycin 1% provided high concentrations (peak level, 559.7 μg/g) in human conjunctiva that were sustained at levels 1 to 2 orders of magnitude higher than those of moxifloxacin 0.5% throughout the 7-day dosing period and for at least 7 days thereafter. Azithromycin also showed an extended half-life (65.7 hours) in conjunctiva relative to that of moxifloxacin (28.6 hours). Accordingly, the concentration of azithromycin was maintained well above the minimum inhibitory concentration required for inhibition of growth of 90% of tested bacterial isolates for at least 7 days, whereas moxifloxacin conjunctival levels fell to levels at or less than the minimum inhibitory concentration required for inhibition of growth of 90% of tested bacterial isolates approximately 24 hours after the last dose. Peak aqueous humor concentration of moxifloxacin was higher (0.77 μg/mL) than that of azithromycin (0.053 μg/mL). No clinically relevant safety findings were observed.

CONCLUSIONS

Azithromycin 1% demonstrated high, therapeutic levels in the conjunctiva that were maintained up to 7 days after completion of a 1-week dosing regimen. Aqueous humor levels, however, were subtherapeutic with this dosing regimen. In comparison, moxifloxacin achieved lower conjunctival tissue levels, but higher aqueous humor levels.

Male mating preference for female survivorship in the seaweed fly Gluma musgravei (Diptera: Coelopidae)

The seaweed fly mating system is characterized by pre-mating struggles during which females exhibit a mate rejection response involving kicking, shaking and abdominal curling. Males must resist rejection until females become passive and allow copulation to take place. However, despite the vigorous nature of the struggle males frequently dismount passive females without attempting copulation. Here we show that rejected females suffered higher post-encounter mortality rates than those accepted by males in the seaweed fly Gluma musgravei. Furthermore, we show that males also preferentially mounted females with higher future longevity. We propose that this male mate choice for female survivorship has evolved as a result of females often having to survive for long periods after mating until suitable oviposition sites become available. Such male preferences for female survivorship may be common in species in which oviposition must sometimes be substantially delayed after mating.

Female mate choice for large males in several species of seaweed fly (Diptera: Coelopidae)

The mating system of the seaweed fly Coelopa frigida involves a vigorous premating struggle during which females attempt to dislodge mounted males by kicking and shaking from side to side. Additionally females can prevent engagement of genitalia by curling their abdomens downwards. Large males gain a mating advantage. Male size is partially determined by a chromosomal inversion polymorphism which is maintained by strong heterosis. Thus female mate choice on the basis of size will affect offspring fitness. We report the occurrence of premating struggles and mate choice for large males in five additional species of seaweed fly, namely, C. nebularum, C. vanduzeei, C. pilipes, Gluma musgravei and G. nitida. Four of these species appear to lack the inversion system, suggesting that mate choice for large males can be maintained in its absence and also evolved before its establishment. Gluma females had stronger preferences than Coelopa females and showed an additional response to mounting, namely, curling their abdomens upwards into the male. This may allow assessment of male size. Copyright 2000 The Association for the Study of Animal Behaviour.

Male choice, willingness to mate and body size in seaweed flies (Diptera: Coelopidae)

The mating system of seaweed flies is characterized by scramble competition and a premating struggle during which females vigorously attempt to remove mounted males and prevent copulation. Here we investigate factors affecting the willingness of males to mate in five species of Coelopa : C. frigida, C. nebularum, C. ursina, C. pilipes and C. vanduzeei. The data from 2000 individual observations of pairs of flies revealed no association between female size and the willingness of males to mate, suggesting that males do not exhibit mate choice for larger, more fecund females. Male willingness to mount was associated with male size in C. frigida, C. nebularum and C. ursina, although not in C. pilipes and C. vanduzeei. There is considerable intraspecific variation in male size in the former three species, including the presence of two almost discrete size classes within C. nebularum. We suggest that males of different sizes in these species may be adopting alternative reproductive strategies. Large males may benefit from increased longevity and their ability to withstand female rejection responses, whereas small males are more active and thus likely to encounter and mount more females. In addition small males develop faster and thus gain earlier access to females. Copyright 1999 The Association for the Study of Animal Behaviour.

Sexual selection as a side-effect of sexual conflict in the seaweed fly, Coelopa ursina (Diptera: Coelopidae)

The mating system of the seaweed fly involves a premating struggle. When mounted, females violently try to remove the male. In this study 48% of premating struggles resulted in successful rejection of the male, 46% in copulation and 6% were terminated by the male. Large males had a mating advantage. However, contrary to what would be predicted if this sexual selection occurred as a result of active female mate choice, we found a positive association between the duration of premating struggles and male size. A positive association was also found between the duration of premating struggles and male mating success, suggesting that large males may benefit through their superior ability to withstand female rejection. Large females rejected males more easily than small females, suggesting that the premating struggle has not evolved to allow mate assessment by females. We conclude that sexual selection is occurring as a side-effect of the female rejection response, which has probably evolved in order to avoid costs associated with copulation. Nevertheless, a sexual size dimorphism has evolved with males being larger and much more variable in size than females. (c) 1998 The Association for the Study of Animal Behaviour.

Heritability of a sexually selected character expressed in both sexes

Sexual selection is thought to be responsible for the evolution of exaggerated male characters and of female mate preferences. Evolutionary mechanisms driven by an advantage to the progeny are only effective if the preferred character has a large genetic component of variance; in most systems in which sexual selection operates, little is known of the relevant genetics. We have measured parent-offspring correlations, and report here that the preferred character (adult size) in seaweed flies has large additive genetic variance in males, but not in females. Virtually all the variance in male size is attributable to a chromosomal inversion system and, consequently, because this system is also a major determinant of larval viability, male size could be used by females as a reliable indicator of offspring survival.