Stimulation of drug metabolism by rifampicin in patients with cirrhosis or cholestasis measured by increased hexobarbital and tolbutamide clearance

The role of CYP3A4 in the biotransformation of bile acids and therapeutic implication for cholestasis

CYP3A4 is a major cytochrome P450. It catalyses a broad range of substrates including xenobiotics such as clinically used drugs and endogenous compounds bile acids. Its function to detoxify bile acids could be used for treating cholestasis, which is a condition characterised by accumulation of bile acids. Although bile acids have important physiological functions, they are very toxic when their concentrations are excessively high. The accumulated bile acids in cholestasis can cause liver and other tissue injuries. Thus, control of the concentrations of bile acids is critical for treatment of cholestasis. CYP3A4 is responsively upregulated in cholestasis mediated by the nuclear receptors farnesol X receptor (FXR) and pregnane X receptor (PXR) as a defence mechanism. However, the regulation of CYP3A4 is complicated by estrogen, which is increased in cholestasis and down regulates CYP3A4 expression. The activity of CYP3A4 is also inhibited by accumulated bile acids due to their property of detergent effect. In some cholestasis cases, genetic polymorphisms of the CYP3A4 and PXR genes may interfere with the adaptive response. Further stimulation of CYP3A4 activity in cholestasis could be an effective approach for treatment of the disease. In this review, we summarise recent progress about the roles of CYP3A4 in the metabolism of bile acids, its regulation and possible implication in the treatment of cholestasis.

Review article: The prevalence and clinical relevance of cytochrome P450 polymorphisms

BACKGROUND

Most drugs currently used in clinical practice are effective in only 25% to 60% of patients, while adverse drug reactions (ADRs) as a consequence of treatment are estimated to cost billions of US dollars and tens of thousands of deaths.

AIM

To review the prevalence and clinical significance of cytochrome P450 polymorphisms.

RESULTS

The cytochrome P450 enzyme families 1-3 are responsible for 70 to 80% of all phase I dependent drug metabolisms. In 90% metabolic activity dependents on six enzymes: CYP1A2, CYP3A, CYP2C9, CYP2C19, CYP2D6 and CYP2E1. Polymorphisms in the CYP450 gene can influence metabolic activity of the subsequent enzymes. A poor metabolizer (PM) has no or very poor enzyme activity. A consequence of PM is drug toxicity if no other metabolic route is available, or when multiple drugs are metabolized by the same cytochrome. In that case dose reduction is an option to prevent toxic effects.

CONCLUSIONS

In the future genotyping should be considered to identify patients who might be at risk of severe toxic responses, in order to guide appropriate individual dosage. Medical therapy should be a close cooperation between clinicians, pharmacologists and laboratory specialists, leading to reduced therapeutic errors, ADRs and health care costs.

Activation of human CYP2C9 promoter and regulation by CAR and PXR in mouse liver

The activity of various genomic segments at the 5'-flanking region of the human CYP2C9 gene in driving gene expression and their involvement in pregnane X receptor (PXR) and constitutive androstane receptor (CAR) mediated activation were evaluated in mouse hepatocytes. Using the genomic sequence of human CYP2C9 as a template, segments covering different regions of CYP2C9 5'-flanking sequences starting from the translation start site were amplified by PCR and inserted into a pGL-3 luciferase vector. Plasmid DNA containing the 0.2K, 1K, 2K, 3K, 5K, or 10K upstream sequences of the CYP2C9 gene were transfected into mouse liver by hydrodynamic delivery, and the activity of each fragment in driving reporter gene expression was assessed. With the exception of the 10K fragment, the level of luciferase activity in transfected mouse liver was similar among the constructs examined. Cotransfection of these reporter constructs with the pCMX-PXR or pCMX-CAR plasmids resulted in a slight increase in luciferase gene expression that could be significantly enhanced by chemical inducers. In mice cotransfected with pCMX-PXR, pregnenolone-16 alpha-carbonitrile (PCN) induced a 20-fold increase in the luciferase level compared to a 70-fold increase induced by rifampicin. Similarly, when animals were cotransfected with the pCMX-CAR plasmid, phenobarbital and 1,4-bis[2-(3,5-dichloropyridyloxy)]benzene enhanced luciferase gene expression by 10- and 57-fold, respectively. The element responsible for PXR- and CAR-mediated activation of luciferase gene expression by chemical inducers was found to reside in the -2000 to -1000 bp region of the 5'-flanking sequence of the CYP2C9 gene. These results prove that PXR and CAR are transcription factors regulating CYP2C9 gene expression.

Roles of rifampicin in drug-drug interactions: underlying molecular mechanisms involving the nuclear pregnane X receptor

Rifampicin, an important drug in the treatment of tuberculosis, is used extensively despite its broad effects on drug-drug interactions, creating serious problems. The clinical importance of such interactions includes autoinduction leading to suboptimal or failed treatment. The concomitantly administered effects of rifampicin on other drugs can result in their altered metabolism or transportation that are metabolised by cytochromes P450 or transported by p-glycoprotein in the gastrointestinal tract and liver. This review paper summarises recent findings with emphases on the molecular mechanisms used to explain these broad drug-drug interactions. In general, rifampicin can act on a pattern: rifampicin activates the nuclear pregnane X receptor that in turn affects cytochromes P450, glucuronosyltransferases and p-glycoprotein activities. This pattern of action may explain many of the rifampicin inducing drug-drug interactions. However, effects through other mechanisms have also been reported and these make any explanation of such drug-drug interactions more complex.

Rifampicin, a keystone inducer of drug metabolism: from Herbert Remmer's pioneering ideas to modern concepts

In 1972, Herbert Remmer's group at the University of Tübingen had developed a micro method to assess cytochrome P450 contents and activities of drug metabolising enzymes in needle biopsies from human liver. Upon application of this method to patients receiving different kinds of drug therapy, Herbert Remmer was the first to describe that total human hepatic cytochrome P450 was markedly elevated by the new anti-tuberculosis drug rifampicin. Similar observations were made for the antimycotic clotrimazol. In 1975, Herbert Remmer's group described the unique species difference that induction of cytochrome P450 by rifampicin did not occur in the rat. After the first clinical reports of impaired effectiveness of oral contraception in persons treated with rifampicin, studies at Herbert Remmer's Institute showed a 4-fold increase, after repetitive rifampicin administration to humans, in the ability of hepatic microsomes to ortho-hydroxylate the contraceptive estrogen ethinylestradiol, compared to microsomes from untreated normal subjects. Subsequent pharmacokinetic investigations were compatible with this induction of the estrogen-2-hydroxylase by rifampicin and provided a rational explanation for the classical drug interaction between rifampicin and oral contraceptives. These early studies, in the 1970s in Tübingen, were followed by further developments. It was realized that the cytochrome P450 isoenzyme 3A4 (CYP3A4) is the major CYP isozyme in the human liver metabolizing a variety of xenobiotics and endobiotics, being also responsible for the 2-hydroxylation of ethinylestradiol. The inducibility of CYP3A4 by barbiturates and rifampicin explains the effects of inducers to enhance the clearance of ethynylestradiol and thereby to reduce the effectiveness of oral contraceptives, rifampicin being one of the most potent inducers of human CYP3A4 gene expression. Since 1998, novel "orphan" members of the nuclear hormone receptor superfamily were cloned from mouse, rat, rabbit, and human origin. These so-called pregnane X receptors (PXR), across species, are activated by inducers of CYP3A4 expression. It now appears that PXR is a key mediator of complex induction processes of xenobiotic processing enzymes, which are triggered by rifampicin and other inducers. Studies of the structure and substrate affinities of PXR have provided the rational explanation of the unique species difference of rifampicin induction between humans and rats that was first described by Herbert Remmer.

Influence of mild liver impairment on the pharmacokinetics and metabolism of bosentan, a dual endothelin receptor antagonist

The purpose of the study was to investigate the effect of mild liver impairment on the pharmacokinetics and metabolism of bosentan. Eight patients with mild liver impairment and 8 matching healthy subjects were treated with single and multiple oral 125-mg doses of bosentan. The pharmacokinetic parameters of bosentan and its metabolites were similar in both groups: geometric means for Cmax and AUC for bosentan were 2534 and 1980 ng/ml and 11,957 and 10,781 ng.h/ml after single doses and were 1831 and 1715 ng/ml and 7216 and 7838 ng.h/ml after multiple doses, respectively, in healthy subjects and patients. In both groups, the exposure to the metabolites was low when compared to that to bosentan. The decrease in exposure to bosentan after multiple dosing, indicative of autoinduction, tended to be less pronounced in patients as compared to healthy subjects. Bosentan was well tolerated in this study. In conclusion, the pharmacokinetics, metabolism, and tolerability of bosentan are similar in healthy subjects and patients with mild liver impairment.

Transcriptional regulation of CYP2C9 gene. Role of glucocorticoid receptor and constitutive androstane receptor

Although cytochrome P450 2C9 (CYP2C9) is a major CYP expressed in the adult human liver, its mechanism of regulation is poorly known. In previous work, we have shown that CYP2C9 is inducible in primary human hepatocytes by xenobiotics including dexamethasone, rifampicin, and phenobarbital. The aim of this work was to investigate the molecular mechanism(s) controlling the inducible expression of CYP2C9. Deletional analysis of CYP2C9 regulatory region (+21 to -2088) in the presence of various hormone nuclear receptors suggested the presence of two functional response elements, a glucocorticoid receptor-responsive element (-1648/-1684) and a constitutive androstane receptor-responsive element (CAR, -1783/-1856). Each of these were characterized by co-transfection experiments, directed mutagenesis, gel shift assays, and response to specific antagonists RU486 and androstanol. By these experiments we located a glucocorticoid-responsive element imperfect palindrome at -1662/-1676, and a DR4 motif at -1803/-1818 recognized and transactivated by human glucocorticoid receptor and by hCAR and pregnane X receptor, respectively. Identification of these functional elements provides rational mechanistic basis for CYP2C9 induction by dexamethasone (submicromolar concentrations), and by phenobarbital and rifampicin, respectively. CYP2C9 appears therefore to be a primary glucocorticoid-responsive gene, which in addition, may be induced by xenobiotics through CAR/pregnane X receptor activation.

Induction of cytochrome P450 (CYP)1A1, CYP1A2, and CYP3A4 but not of CYP2C9, CYP2C19, multidrug resistance (MDR-1) and multidrug resistance associated protein (MRP-1) by prototypical inducers in human hepatocytes

Human hepatocytes cultured serum-free for up to 6 weeks were used to study expression and induction of enzymes and membrane transport proteins involved in drug metabolism. Phase I drug metabolizing enzymes cytochrome P450 (CYP)1A1, CYP1A2, CYP2C9, CYP2C19, CYP2E1, and CYP3A4 were detected by Western blot analyses and, when appropriate, by enzymatic assays for ethoxyresorufin-O-deethylase(EROD)-activity and testosterone-6beta-hydroxylase(T6H)-activity. Expression of the membrane transporter multi-drug resistance protein (P-glycoprotein, MDR-1), multidrug resistance-associated protein (MRP-1), and lung-resistance protein (LRP) was maintained during the culture as detected by RT-PCR and Western blot analyses. Model inducers like rifampicin, phenobarbital, or 3-methylcholanthrene and beta-naphtoflavone were able to induce CYP1A or CYP3A4 as well as EROD or T6H activities for up to 30 days. CYP2C9, CYP2C19 and CYP2E1 expression was maintained but not inducible for 48 days. Also, rifampicin and phenobarbital were unable to increase MDR-1 and MRP-1 protein levels significantly.

Rifampicin treatment greatly increases the apparent oral clearance of quinidine

We investigated the effect of cytochrome P450 induction by rifampicin on the in vivo oxidative metabolism of quinidine. The pharmacokinetics of a 200 mg oral single dose quinidine were studied before and after one week of daily treatment with 600 mg rifampicin in six healthy young male volunteers. Biomarker reactions of cytochrome P450 isozyme activities in the form of caffeine, sparteine, mephenytoin, tolbutamide and cortisol metabolism were applied. The median total apparent oral clearance and partial clearance by 3-hydroxylation of quinidine increased 9 times. The partial clearance by N-oxidation increased 6 times. The Cmax and the elimination half life were reduced 3 times. No statistically significant changes were found for quinidine tmax and renal clearance. The cortisol metabolic ratio increased 5 times, while no statistically significant effects were seen for other CYP marker reactions. The results indicate that the inductive effect of rifampicin is likely to be of clinical relevance particularly when used concomitantly with drugs metabolized by CYP3A4.

Microsomal prediction of in vivo clearance of CYP2C9 substrates in humans

AIMS

To assess the utility of human hepatic microsomes for predicting in vivo intrinsic clearance (CLint ) via the use of four cytochrome P450 2C9 substrates: phenytoin, tolbutamide (S)-ibuprofen (two pathways) and diclofenac, and to examine the role of exogenous albumin within the microsomal incubation.

METHODS

V max, Km and CLint (defined as V max/Km ratio) were estimated under initial rate conditions for five pathways of metabolism in a bank of 15 human hepatic microsomal samples and were scaled to in vivo units using the microsomal protein index. Non-metabolic related binding in microsomes was measured for phenytoin and tolbutamide in the presence and absence of albumin.

RESULTS

Microsomal CLint values differed by over two orders of magnitude, with the means ranging from 0.18 (phenytoin) to 40.70 (diclofenac) microl min-1 mg-1 microsomal protein. When these data were scaled and compared with published in vivo studies a similar rank order was obtained, however, the actual CLint tended to be underpredicted. While the in vivo unbound Km for phenytoin, 1-5 micron is substantially lower than the value determined in microsomes based on total concentrations (56 micron), correction for the in vitro binding reduces this value to 20 micron and 6 micron in the absence and presence of albumin, respectively. Similar trends were seen with tolbutamide Km.

CONCLUSIONS

An appreciation of the utility of in vitro prediction can be best achieved when the range of CLint values predicted from the individual hepatic microsomal samples are compared with the range of individual in vivo CLint values reported in the literature. The degree of underprediction is less evident using the range than the mean data and no consistent advantage in adding albumin to the incubation media is apparent.

Assessment of liver metabolic function. Clinical implications

Inter- and intraindividual variability in pharmacokinetics of most drugs is largely determined by variable liver function as described by parameters of hepatic blood flow and metabolic capacity. These parameters may be altered as a result of disease affecting the liver, genetic differences in metabolising enzymes, and various types of drug interactions, including enzyme induction, enzyme inhibition or down-regulation. With the now known large number of drug metabolising enzymes, their differential substrate specificity, and their differential induction or inhibition, each test substance of liver function should be used as a probe for its specific metabolising enzyme. Thus, the concept of model test-substances providing general information about liver function has severe limitations. To test the metabolic activity of several enzymes, either several test substances may be given (cocktail approach) or several metabolites of a single test substance may be analysed (metabolic fingerprint approach). The enzyme-specific analysis of liver function results in a preference for analysis of the metabolites rather than analysis of the clearance of the parent test substance. There are specific methods to quantify the activity of cytochrome P450 enzymes such as CYP1A2, CYP2C9, CYP2C19MEPH, CYP2D6, CYP2E1, and CYP3A, and phase II enzymes, such as glutathione S-transferases, glucuronyl-transferases or N-acetyltransferases, in vivo. Interactions based on competitive or noncompetitive inhibition should be analysed specifically for the cytochrome P450 enzyme involved. At least 5 different types of cytochrome P450 enzyme induction may result in major variability of hepatic function; this may be quantified by biochemical parameters, clearance methods, or highly enzyme-specific methods such as Western blot analysis or molecular biological techniques such as mRNA quantification in blood and tissues. Therapeutic drug monitoring is already implicitly used for quantification of the enzyme activities relevant for a specific drug. Selective impairment of hepatic enzymes due to gene mutations may have an effect on the pharmacokinetics of certain drugs similar to that caused by cirrhosis. Assessment of this heritable source of variability in liver function is possible by in vivo or ex vivo enzymological methods. For genetically polymorphic enzymes and carrier proteins involved in drug disposition, molecular genetic methods using a patient's blood sample may be used for classification of the individual into: (i) the impaired or poor metaboliser (homozygous deficient); (ii) the extensive (homozygous active) metaboliser group; and (iii) the moderately extensive metaboliser (heterozygous) group. For hepatic blood flow determinations, galactose or sorbitol given at relatively low doses may be much better indicators than the indocyanine green.(ABSTRACT TRUNCATED AT 400 WORDS)

Teicoplanin with other drugs: possible pharmacological interactions

The contemporaneous employment of two or more drugs may present the risk of modifying the required therapeutic effect or producing adverse reactions. These interactions are of a pharmacokinetic and pharmacodynamic type. Teicoplanin is an antibiotic with a glycopeptide structure, produced by Actinoplanes teichomyceticus, active against both anaerobic and aerobic Gram-positive bacteria that are resistant to various chemotherapeutic drugs (beta-lactam and macrolide antibiotics, tetracyclines, co-trimoxazole). Then the aim of this work was to verify experimentally the possible pharmacological interactions between teicoplanin and oral hypoglycemic (phenformin and glibenclamide), or oral anticoagulant (warfarin) or bronchodilator (theophylline) drugs. Teicoplanin (3-15 mg/kg/die i.p. for 4 days) administration to the rat did not significantly (p > 0.05) modify the glycemia, prothrombin and partial thromboplastin times, the hypoglycemic effect of phenformin (2.5 mg/kg/die os for 4 days) and glibenclamide (0.5 mg/kg/die os for 4 days) or the anticoagulant effect of warfarin (0.5 mg/kg/die os for 4 days); moreover it did not significantly (p > 0.05) modify the pharmacokinetics of aminophylline (5 mg/kg i.v.) on the rabbit. In conclusion our results documented that teicoplanin does not interfere with phenformin, glibenclamide, or sodium warfarin activities nor with aminophylline pharmacokinetics.

Pharmacokinetic drug interactions with rifampicin

Rifampicin, an antituberculosis drug, is usually administered for 4 to 12 months with other antituberculosis drugs or medications from other classes. A potential for drug interactions often exists because rifampicin is a potent inducer of hepatic drug metabolism, as evidenced by a proliferation of smooth endoplasmic reticulum and an increase in the cytochrome P450 content in the liver. The induction is a highly selective process and not every drug metabolised via oxidation is affected. Case reports and studies have demonstrated enhanced metabolism of several drugs; most of these interactions are clinically important. At the start of rifampicin treatment, and again at the end, clinicians must check the dosages of any accompanying medications with which rifampicin may potentially interact. Monitoring of clinical response and blood drug concentrations is essential to adjust the drug dosage during rifampicin therapy. Rifampicin also interacts with cholephils such as bilirubin and bromosulphthalein. Its pharmacokinetics are reported to be altered by ethambutol, p-aminosalicylic acid (through its excipient component), ketoconazole, cyclosporin, clofazimine, probenecid and phenobarbital through one or other of the following mechanisms--impaired absorption of rifampicin, competition between the drug and rifampicin for hepatic uptake and altered hepatic metabolism of rifampicin. Most interactions affecting rifampicin have been relatively minor or are not expected to alter its therapeutic efficacy.

Teicoplanin does not modify the hypoglycemic effects of phenformin or glibenclamide, nor the anticoagulant action of warfarin. Experimental study

Eventual pharmacological interactions induced by teicoplanin administration associated with oral hypoglycemic (phenformin and glibenclamide) and oral anticoagulant (warfarin) drugs have been experimentally evaluated. The administration of teicoplanin (3-15 mg/kg/die by endoperitoneal route) to the rat for 4 days did not significantly (P greater than 0.05) modify glycemia, prothrombin and partial thromboplastin times, the hypoglycemic effect of phenformin (2.5 mg/kg/die/4 days) or glibenclamide (0.5 mg/kg/die/4 days) nor the anticoagulant effect of warfarin (0.5 mg/kg/die/4 days). In conclusion, our results document that teicoplanin does not interfere with the activity of phenformin, glibenclamide or sodium warfarin.

Expression of cytochrome P-450 enzymes in cultured human hepatocytes

Hepatocytes from adult and newborn humans were put into primary culture and exposed to phenobarbital, 3-methylcholanthrene, or rifampicin, three well-known inducers of cytochrome P-450 in animals. The expression of four cytochrome P-450 enzymes (or groups of enzymes, namely P-450 IIIA, P-450 IIC8/9/10, P-450 IIE1, and P-450 IA2) was investigated. These enzymes were found to remain expressed during the period of culture studied. Treatment with the inducers for three days resulted in different responses, depending upon the inducer and the enzyme. Phenobarbital and rifampicin increased P-450 IIC8/9/10 mRNA transcripts and the corresponding protein, while 3-methylcholanthrene was ineffective. Both P-450 IIIA mRNA and protein were strongly induced by rifampicin. All of the hepatocytes were found to synthesize P-450 IIIA in response to rifampicin, as shown by immunoperoxidase staining. P-450 IIIA expression was not affected by phenobarbital and was decreased by 3-methylcholanthrene. P-450s IA2 and IIE1 decreased to 25-50% of the initial level during these cultures. P-450 IA2 and ethoxyresorufin O-deethylase activity (which is a monooxygenase activity related to P-450 IA family) were increased only by 3-methylcholanthrene and did not respond to the other inducers. P-450 IIE1 was not induced by any of these compounds. P-450 IIC8/9/10 and P-450 IIIA mRNA levels were also measured in human hepatocytes from one newborn. P-450 IIC8/9/10 was barely expressed in freshly isolated cells but increased dramatically with time in culture. P-450 IIIA transcripts were abundant in both freshly isolated and cultured cells derived from a newborn. These results clearly demonstrate that human hepatocytes continue to express cytochrome P-450 enzymes and respond to inducers in culture. This model system provides a useful approach for investigating the effects of drugs on maturation and expression of drug-metabolizing enzymes in human liver.

Disposition of hexobarbital in intra- and extrahepatic cholestasis in man and the influence of drug metabolism-inducing agents

The pharmacokinetics of intravenously infused hexobarbital was studied in 10 patients with intrahepatic cholestasis and in 9 with extrahepatic biliary obstruction. The results were compared with those obtained in 16 healthy young volunteers and 5 older patients with normal liver function. After infusion, the plasma concentrations showed a rapid initial decline (alpha-phase) and subsequently a slower decrease (beta-phase). The half-life of a latter phase was 323 +/- 84 min in the healthy group, 357 +/- 151 min in the patients with intrahepatic cholestasis and 344 +/- 115 min in the group with biliary obstruction; the clearances were 3.41 +/- 0.90, 4.08 +/- 1.95 and 3.81 +/- 1.97 ml x min-1 x kg-1, respectively. The differences were not statistically significant. The mean volume of the central compartment of distribution and the steady state volume of distribution were not significantly different. In two patients hexobarbital clearance during cholestasis was greater than after it had subsided. After treatment of 11 patients with cholestasis with drug metabolism-inducing agents (phenobarbital, rifampicin or phenytoin), the half-life of hexobarbital was significantly shortened and the mean value of hexobarbital clearance was more than doubled.

The effect of rifampicin on norethisterone pharmacokinetics

The pharmacokinetics of norethisterone have been studied in 8 women during and one month after treatment with rifampicin (450--600 mg/day). Rifampicin caused a significant reduction in the A.U.C. of a single dose of 1 mg norethisterone from 37.8 +/- 13.1 to 21.9 +/- 5.9 ng/ml X h (p less than 0.01). The plasma norethisterone half life (beta-phase) was also reduced from 6.2 +/- 1.7 to 3.2 +/- 1.0 h (p less than 0.0025). In one additional woman on long term oral contraceptive therapy the 12 hour plasma norethisterone concentration was reduced by rifampicin from 12.3 ng/ml to 2.3 ng/ml. Rifampicin caused a significant increase in antipyrine clearance, 6 beta-hydroxycortisol excretion and plasma gamma-glutamyltranspeptidase activity but there was no significant correlations between changes in these indices of liver microsomal enzyme induction. There was a significant correlation between the percentage increase in antipyrine clearance and the percentage decrease in norethisterone A.U.C. during rifampicin. The changes in norethisterone pharmacokinetics during rifampicin therapy are compatible with the known enzyme inducing effect of rifampicin.

m-Trifluoromethyl-alpha-ethylbenzhydrol: a new enzyme inducer

The enzyme inducing effect of m-trifluoromethyl-alpha-ethylbenzhydrol (RGH-3332) has been studied in man, rat and mouse. In man, RGH-3332 decreased the half-life of antipyrine and tolbutamide and increased D-glucaric acid excretion. In rat and mouse the half-life of antipyrine was shortened. It was concluded that in all three species man, rat and mouse the liver microsomal drug metabolizing enzyme system was induced by RGH-3332. No side-effects were found on treatment with RGH-3332.