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Li C, Jia WW, Yang JL, Cheng C, Olaleye OE. Multi-compound and drug-combination pharmacokinetic research on Chinese herbal medicines. Acta Pharmacol Sin 2022; 43:3080-3095. [PMID: 36114271 PMCID: PMC9483253 DOI: 10.1038/s41401-022-00983-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/12/2022] [Indexed: 12/02/2022] Open
Abstract
Traditional medicine has provided a basis for health care and disease treatment to Chinese people for millennia, and herbal medicines are regulated as drug products in China. Chinese herbal medicines have two features. They normally possess very complex chemical composition. This makes the identification of the constituents that are together responsible for the therapeutic action of an herbal medicine challenging, because how to select compounds from an herbal medicine for pharmacodynamic study has been a big hurdle in such identification efforts. To this end, a multi-compound pharmacokinetic approach was established to identify potentially important compounds (bioavailable at the action loci with significant exposure levels after dosing an herbal medicine) and to characterize their pharmacokinetics and disposition. Another feature of Chinese herbal medicines is their typical use as or in combination therapies. Coadministration of complex natural products and conventional synthetic drugs is prevalent worldwide, even though it remains very controversial. Natural product–drug interactions have raised wide concerns about reduced drug efficacy or safety. However, growing evidence shows that incorporating Chinese herbal medicines into synthetic drug-based therapies delivers benefits in the treatment of many multifactorial diseases. To address this issue, a drug-combination pharmacokinetic approach was established to assess drug–drug interaction potential of herbal medicines and degree of pharmacokinetic compatibility for multi-herb combination and herbal medicine–synthetic drug combination therapies. In this review we describe the methodology, techniques, requirements, and applications of multi-compound and drug-combination pharmacokinetic research on Chinese herbal medicines and to discuss further development for these two types of pharmacokinetic research.
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Exploring Herbal Medicine Use during Palliative Cancer Care: The Integrative Physician as a Facilitator of Pharmacist-Patient-Oncologist Communication. Pharmaceuticals (Basel) 2020; 13:ph13120455. [PMID: 33322582 PMCID: PMC7763590 DOI: 10.3390/ph13120455] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/08/2020] [Accepted: 12/09/2020] [Indexed: 12/13/2022] Open
Abstract
Oncology patients frequently use herbal and other forms of complementary medicine, often without the knowledge of oncologists, pharmacists, and other healthcare professionals responsible for their care. Oncology healthcare professionals may lack the knowledge needed to guide their patients on the safe and effective use of herbal medicinal products, a number of which have potentially harmful effects, which include direct toxicity and negative herb–drug interactions. The current review addresses the prevalence and expectations of oncology patients from herbal medicine, as well as evidence for the beneficial or harmful effects of this practice (potential and actual), especially when the herbal products are used in conjunction with anticancer agents. Models of integrative oncology care are described, in which open and effective communication among oncologists, pharmacists, and integrative physicians on the use of herbal medicine by their patients occurs. This collaboration provides patients with a nonjudgmental and multidisciplinary approach to integrative medicine, echoing their own health-belief models of care during conventional cancer treatments. The role of the integrative physician is to facilitate this process, working with oncologists and pharmacists in the fostering of patient-centered palliative care, while ensuring a safe and effective treatment environment. Case scenario: W. is a 56 year old female artist who was recently diagnosed with localized hormone receptor-positive breast cancer. Following lumpectomy and sentinel node dissection, she is scheduled to begin adjuvant chemotherapy with a regimen which will include adriamycin, cyclophosphamide, and paclitaxel (AC-T protocol). She is worried about developing peripheral neuropathy and its impact on her ability to paint, and she asks about a number of dietary supplements which she heard could prevent this from happening: omega-3, vitamin E, alpha-lipoic acid, and acetyl-l-carnithine. She is concerned, however, that the supplements may negatively interact with her chemotherapy regimen.
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Nicolussi S, Drewe J, Butterweck V, Meyer Zu Schwabedissen HE. Clinical relevance of St. John's wort drug interactions revisited. Br J Pharmacol 2020; 177:1212-1226. [PMID: 31742659 PMCID: PMC7056460 DOI: 10.1111/bph.14936] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 11/01/2019] [Accepted: 11/10/2019] [Indexed: 12/22/2022] Open
Abstract
The first clinically relevant reports of preparations of St. John's wort (SJW), a herbal medicine with anti‐depressant effects, interacting with other drugs, altering their bioavailability and efficacy, were published about 20 years ago. In 2000, a pharmacokinetic interaction between SJW and cyclosporine caused acute rejection in two heart transplant patients. Since then, subsequent research has shown that SJW altered the pharmacokinetics of drugs such as digoxin, tacrolimus, indinavir, warfarin, alprazolam, simvastatin, or oral contraceptives. These interactions were caused by pregnane‐X‐receptor (PXR) activation. Preparations of SJW are potent activators of PXR and hence inducers of cytochrome P450 enzymes (most importantly CYP3A4) and P‐glycoprotein. The degree of CYP3A4 induction correlates significantly with the hyperforin content in the preparation. Twenty years after the first occurrence of clinically relevant pharmacokinetic drug interactions with SJW, this review revisits the current knowledge of the mechanisms of action and on how pharmacokinetic drug interactions with SJW could be avoided. Linked Articles This article is part of a themed section on The Pharmacology of Nutraceuticals. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.6/issuetoc
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Affiliation(s)
- Simon Nicolussi
- Medical Research, Max Zeller Söhne AG, Romanshorn, Switzerland
| | - Jürgen Drewe
- Medical Research, Max Zeller Söhne AG, Romanshorn, Switzerland
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Intravenous formulation of Panax notoginseng root extract: human pharmacokinetics of ginsenosides and potential for perpetrating drug interactions. Acta Pharmacol Sin 2019; 40:1351-1363. [PMID: 31358899 DOI: 10.1038/s41401-019-0273-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 06/11/2019] [Indexed: 12/12/2022] Open
Abstract
XueShuanTong, a lyophilized extract of Panax notoginseng roots (Sanqi) for intravenous administration, is extensively used as add-on therapy in the treatment of ischemic heart and cerebrovascular diseases and comprises therapeutically active ginsenosides. Potential for XueShuanTong-drug interactions was determined; the investigation focused on cytochrome P450 (CYP)3A induction and organic anion-transporting polypeptide (OATP)1B inhibition. Ginsenosides considerably bioavailable for drug interactions were identified by dosing XueShuanTong in human subjects and their interaction-related pharmacokinetics were determined. The CYP3A induction potential was determined by repeatedly dosing XueShuanTong for 15 days in human subjects and by treating cryopreserved human hepatocytes with circulating ginsenosides; midazolam served as a probe substrate. Joint inhibition of OATP1B by XueShuanTong ginsenosides was assessed in vitro, and the data were processed using the Chou-Talalay method. Samples were analyzed by liquid chromatography/mass spectrometry. Ginsenosides Rb1, Rd, and Rg1 and notoginsenoside R1 were the major circulating XueShuanTong compounds; their interaction-related pharmacokinetics comprised compound dose-dependent levels of systemic exposure and, for ginsenosides Rb1 and Rd, long terminal half-lives (32‒57 and 58‒307 h, respectively) and low unbound fractions in plasma (0.8%‒2.9% and 0.4%‒3.0%, respectively). Dosing XueShuanTong did not induce CYP3A. Based on the pharmacokinetics and inhibitory potency of the ginsenosides, XueShuanTong was predicted to have high potential for OATP1B3-mediated drug interactions (attributed chiefly to ginsenoside Rb1) suggesting the need for further model-based determination of the interaction potential for XueShuanTong and, if necessary, a clinical drug interaction study. Increased awareness of ginsenosides' pharmacokinetics and XueShuanTong-drug interaction potential will help ensure the safe use of XueShuanTong and coadministered synthetic drugs.
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Johnson EJ, González-Peréz V, Tian DD, Lin YS, Unadkat JD, Rettie AE, Shen DD, McCune JS, Paine MF. Selection of Priority Natural Products for Evaluation as Potential Precipitants of Natural Product-Drug Interactions: A NaPDI Center Recommended Approach. Drug Metab Dispos 2018; 46:1046-1052. [PMID: 29735752 DOI: 10.1124/dmd.118.081273] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/03/2018] [Indexed: 11/22/2022] Open
Abstract
Pharmacokinetic interactions between natural products (NPs) and conventional medications (prescription and nonprescription) are a longstanding but understudied problem in contemporary pharmacotherapy. Consequently, there are no established methods for selecting and prioritizing commercially available NPs to evaluate as precipitants of NP-drug interactions (NPDIs). As such, NPDI discovery remains largely a retrospective, bedside-to-bench process. This Recommended Approach, developed by the Center of Excellence for Natural Product Drug Interaction Research (NaPDI Center), describes a systematic method for selecting NPs to evaluate as precipitants of potential clinically significant pharmacokinetic NPDIs. Guided information-gathering tools were used to score, rank, and triage NPs from an initial list of 47 candidates. Triaging was based on the presence and/or absence of an NPDI identified in a clinical study (≥20% or <20% change in the object drug area under the concentration vs. time curve, respectively), as well as mechanistic and descriptive in vitro and clinical data. A qualitative decision-making tool, termed the fulcrum model, was developed and applied to 11 high-priority NPs for rigorous study of NPDI risk. Application of this approach produced a final list of five high-priority NPs, four of which are currently under investigation by the NaPDI Center.
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Affiliation(s)
- Emily J Johnson
- Center of Excellence for Natural Product Drug Interaction Research, Spokane, Washington (Y.S.L., J.D.U., A.E.R., D.D.S., J.S.M., M.F.P.); Department of Pharmaceutical Sciences, Washington State University, Spokane, Washington (E.J.J., V.G.-P., D.-D.T., M.F.P.); Department of Pharmaceutics (Y.S.L., J.D.U., D.D.S., J.S.M.) and Department of Medicinal Chemistry (A.E.R.), University of Washington, Seattle, Washington; and Department of Population Sciences, City of Hope, Duarte, California (J.S.M.)
| | - Vanessa González-Peréz
- Center of Excellence for Natural Product Drug Interaction Research, Spokane, Washington (Y.S.L., J.D.U., A.E.R., D.D.S., J.S.M., M.F.P.); Department of Pharmaceutical Sciences, Washington State University, Spokane, Washington (E.J.J., V.G.-P., D.-D.T., M.F.P.); Department of Pharmaceutics (Y.S.L., J.D.U., D.D.S., J.S.M.) and Department of Medicinal Chemistry (A.E.R.), University of Washington, Seattle, Washington; and Department of Population Sciences, City of Hope, Duarte, California (J.S.M.)
| | - Dan-Dan Tian
- Center of Excellence for Natural Product Drug Interaction Research, Spokane, Washington (Y.S.L., J.D.U., A.E.R., D.D.S., J.S.M., M.F.P.); Department of Pharmaceutical Sciences, Washington State University, Spokane, Washington (E.J.J., V.G.-P., D.-D.T., M.F.P.); Department of Pharmaceutics (Y.S.L., J.D.U., D.D.S., J.S.M.) and Department of Medicinal Chemistry (A.E.R.), University of Washington, Seattle, Washington; and Department of Population Sciences, City of Hope, Duarte, California (J.S.M.)
| | - Yvonne S Lin
- Center of Excellence for Natural Product Drug Interaction Research, Spokane, Washington (Y.S.L., J.D.U., A.E.R., D.D.S., J.S.M., M.F.P.); Department of Pharmaceutical Sciences, Washington State University, Spokane, Washington (E.J.J., V.G.-P., D.-D.T., M.F.P.); Department of Pharmaceutics (Y.S.L., J.D.U., D.D.S., J.S.M.) and Department of Medicinal Chemistry (A.E.R.), University of Washington, Seattle, Washington; and Department of Population Sciences, City of Hope, Duarte, California (J.S.M.)
| | - Jashvant D Unadkat
- Center of Excellence for Natural Product Drug Interaction Research, Spokane, Washington (Y.S.L., J.D.U., A.E.R., D.D.S., J.S.M., M.F.P.); Department of Pharmaceutical Sciences, Washington State University, Spokane, Washington (E.J.J., V.G.-P., D.-D.T., M.F.P.); Department of Pharmaceutics (Y.S.L., J.D.U., D.D.S., J.S.M.) and Department of Medicinal Chemistry (A.E.R.), University of Washington, Seattle, Washington; and Department of Population Sciences, City of Hope, Duarte, California (J.S.M.)
| | - Allan E Rettie
- Center of Excellence for Natural Product Drug Interaction Research, Spokane, Washington (Y.S.L., J.D.U., A.E.R., D.D.S., J.S.M., M.F.P.); Department of Pharmaceutical Sciences, Washington State University, Spokane, Washington (E.J.J., V.G.-P., D.-D.T., M.F.P.); Department of Pharmaceutics (Y.S.L., J.D.U., D.D.S., J.S.M.) and Department of Medicinal Chemistry (A.E.R.), University of Washington, Seattle, Washington; and Department of Population Sciences, City of Hope, Duarte, California (J.S.M.)
| | - Danny D Shen
- Center of Excellence for Natural Product Drug Interaction Research, Spokane, Washington (Y.S.L., J.D.U., A.E.R., D.D.S., J.S.M., M.F.P.); Department of Pharmaceutical Sciences, Washington State University, Spokane, Washington (E.J.J., V.G.-P., D.-D.T., M.F.P.); Department of Pharmaceutics (Y.S.L., J.D.U., D.D.S., J.S.M.) and Department of Medicinal Chemistry (A.E.R.), University of Washington, Seattle, Washington; and Department of Population Sciences, City of Hope, Duarte, California (J.S.M.)
| | - Jeannine S McCune
- Center of Excellence for Natural Product Drug Interaction Research, Spokane, Washington (Y.S.L., J.D.U., A.E.R., D.D.S., J.S.M., M.F.P.); Department of Pharmaceutical Sciences, Washington State University, Spokane, Washington (E.J.J., V.G.-P., D.-D.T., M.F.P.); Department of Pharmaceutics (Y.S.L., J.D.U., D.D.S., J.S.M.) and Department of Medicinal Chemistry (A.E.R.), University of Washington, Seattle, Washington; and Department of Population Sciences, City of Hope, Duarte, California (J.S.M.)
| | - Mary F Paine
- Center of Excellence for Natural Product Drug Interaction Research, Spokane, Washington (Y.S.L., J.D.U., A.E.R., D.D.S., J.S.M., M.F.P.); Department of Pharmaceutical Sciences, Washington State University, Spokane, Washington (E.J.J., V.G.-P., D.-D.T., M.F.P.); Department of Pharmaceutics (Y.S.L., J.D.U., D.D.S., J.S.M.) and Department of Medicinal Chemistry (A.E.R.), University of Washington, Seattle, Washington; and Department of Population Sciences, City of Hope, Duarte, California (J.S.M.)
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Phytotherapeutics: The Emerging Role of Intestinal and Hepatocellular Transporters in Drug Interactions with Botanical Supplements. Molecules 2017; 22:molecules22101699. [PMID: 29065448 PMCID: PMC6151444 DOI: 10.3390/molecules22101699] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 09/30/2017] [Accepted: 10/02/2017] [Indexed: 01/17/2023] Open
Abstract
In herbalism, botanical supplements are commonly believed to be safe remedies, however, botanical supplements and dietary ingredients interact with transport and metabolic processes, affecting drug disposition. Although a large number of studies have described that botanical supplements interfere with drug metabolism, the mode of their interaction with drug transport processes is not well described. Such interactions may result in serious undesired effects and changed drug efficacy, therefore, some studies on interaction between botanical supplement ingredients and drug transporters such as P-gp and OATPs are described here, suggesting that the interaction between botanical supplements and the drug transporters is clinically significant.
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Meyer JR, Generali JA, Karpinski JL. Evaluation of Herbal–Drug Interaction Data in Tertiary Resources. Hosp Pharm 2017. [DOI: 10.1177/001857870403900210] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Joyce A. Generali
- Drug Information Center, University of Kansas Medical Center, Kansas City, KS
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Turton-Weeks SM, Barone GW, Gurley BJ, Ketel BL, Lightfoot ML, Abul-Ezz SR. St John's Wort: A Hidden Risk for Transplant Patients. Prog Transplant 2016; 11:116-20. [PMID: 11871046 DOI: 10.1177/152692480101100207] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Herbal medications may cause prescription drug interactions in transplant recipients. After 2 of our kidney transplant recipients started self-medicating with St John's wort, their cyclosporine concentrations were consistently documented to be subtherapeutic. While on St John's wort, one patient developed acute rejection possibly due to low cyclosporine concentrations. Termination of St John's wort returned both patients' cyclosporine concentrations to therapeutic values. Based on the Naranjo Adverse Drug Reaction Probability Scale, our report would achieve a “probable” score, which supports the existence of a St John's wort–cyclosporine adverse drug interaction. St John's wort may induce cytochrome P-450 3A4 activity and/or P-glycoprotein expression, which are both involved in the metabolism and absorption of cyclosporine. Patients using St John's wort concomitantly with cyclosporine or other medications with similar absorption and/or metabolism to cyclosporine need close monitoring. Transplant coordinators are in a critical position to educate transplant recipients about the potential risks of herbal medication usage.
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Affiliation(s)
- S M Turton-Weeks
- University of Arkansas for Medical Sciences, Little Rock, Ark., USA
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Stieger B, Mahdi ZM, Jäger W. Intestinal and Hepatocellular Transporters: Therapeutic Effects and Drug Interactions of Herbal Supplements. Annu Rev Pharmacol Toxicol 2016; 57:399-416. [PMID: 27648763 DOI: 10.1146/annurev-pharmtox-010716-105010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Herbal supplements are generally considered safe; however, drug disposition is influenced by the interactions of herbal supplements and food constituents with transport and metabolic processes. Although the interference of herbal supplements with drug metabolism has been studied extensively, knowledge of how they interact with the drug transport processes is less advanced. Therefore, we describe here specific examples of experimental and human interaction studies of herbal supplement components with drug transporters addressing, for example, organic anion transporting polypeptides or P-glycoprotein, as such interactions may lead to severe side effects and altered drug efficacy. Hence, it is clearly necessary to increase the awareness of the clinical relevance of the interference of herbal supplements with the drug transport processes.
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Affiliation(s)
- Bruno Stieger
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland;
| | - Zainab M Mahdi
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland;
| | - Walter Jäger
- Division of Clinical Pharmacy and Diagnostics, Department of Pharmaceutical Chemistry, University of Vienna, A-1090 Vienna, Austria;
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Beer AM, Loew D, Weber PT, Herzog-Niescery J, Gude P. [Possible risks of phytopharmaceuticals in the perioperative period]. MMW Fortschr Med 2016; 158:72-6. [PMID: 27596200 DOI: 10.1007/s15006-016-8665-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- André-Michael Beer
- Klinik für Naturheilkunde, Klinik Blankenstein, Hattingen, Deutschland. .,Lehrbereich Naturheilkunde, Ruhr-Universität Bochum, Im Vogelsang 5-11, D-45527, Hattingen, Deutschland.
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Affiliation(s)
- Gary W Barone
- Associate Professor, Department of Surgery University of Arkansas for Medical Sciences 4301 West Markham Street Little Rock, Arkansas 72205-7101 FAX 501/686-5725
| | - Bill J Gurley
- Associate Professor, Department of Pharmaceutical Sciences University of Arkansas for Medical Sciences Little Rock, Arkansas
| | - Beverley L Ketel
- Associate Professor, Department of Surgery University of Arkansas for Medical Sciences Little Rock, Arkansas
| | - Meredith L Lightfoot
- Resident Department of Surgery University of Arkansas for Medical Sciences Little Rock, Arkansas
| | - Sameh R Abul-Ezz
- Associate Professor, Department of Medicine University of Arkansas for Medical Sciences Little Rock, Arkansas
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Friedland K, Harteneck C. Hyperforin: To Be or Not to Be an Activator of TRPC(6). Rev Physiol Biochem Pharmacol 2015; 169:1-24. [DOI: 10.1007/112_2015_25] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Awortwe C, Fasinu PS, Rosenkranz B. Application of Caco-2 cell line in herb-drug interaction studies: current approaches and challenges. JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES 2014; 17:1-19. [PMID: 24735758 DOI: 10.18433/j30k63] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The Caco-2 model is employed in pre-clinical investigations to predict the likely gastrointestinal permeability of drugs because it expresses cytochrome P450 enzymes, transporters, microvilli and enterocytes of identical characteristics to the human small intestine. The FDA recommends this model as integral component of the Biopharmaceutics Classification System (BCS). Most dedicated laboratories use the Caco-2 cell line to screen new chemical entities through prediction of its solubility, bioavailability and the possibility of drug-drug or herb-drug interactions in the gut lumen. However, challenges in the inherent characteristics of Caco-2 cell and inter-laboratory protocol variations have resulted to generation of irreproducible data. These limitations affect the extrapolation of data from pre-clinical research to clinical studies involving drug-drug and herb-drug interactions. This review addresses some of these caveats and enumerates the plausible current and future approaches to reduce the anomalies associated with Caco-2 cell line investigations focusing on its application in herb-drug interactions.
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Affiliation(s)
- Charles Awortwe
- Division of Clinical Pharmacology, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, Cape Town, South Africa
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Affiliation(s)
| | - Jorge Rakela
- Transplant Center, Mayo Clinic, Phoenix, Arizona
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Hu M, Fan L, Zhou HH, Tomlinson B. Theranostics meets traditional Chinese medicine: rational prediction of drug–herb interactions. Expert Rev Mol Diagn 2014; 12:815-30. [DOI: 10.1586/erm.12.126] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Izzo AA. Interactions between herbs and conventional drugs: overview of the clinical data. Med Princ Pract 2012; 21:404-28. [PMID: 22236736 DOI: 10.1159/000334488] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Accepted: 10/05/2011] [Indexed: 12/25/2022] Open
Abstract
This article provides an overview of the clinical evidence of interactions between herbal and conventional medicines. Herbs involved in drug interactions--or that have been evaluated in pharmacokinetic trials--are discussed in this review. While many of the interactions reported are of limited clinical significance and many herbal products (e.g. black cohosh, saw palmetto, echinacea, hawthorn and valerian) seem to expose patients to minor risk under conventional pharmacotherapy, a few herbs, notably St. John's wort, may provoke adverse events sufficiently serious to endanger the patients' health. Healthcare professionals should remain vigilant for potential interactions between herbal medicines and prescribed drugs, especially when drugs with a narrow therapeutic index are used.
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Affiliation(s)
- Angelo A Izzo
- Department of Experimental Pharmacology, Federico II University of Naples, Naples, Italy.
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Dostalek M, Pistovcakova J, Jurica J, Sulcova A, Tomandl J. THE EFFECT OF ST JOHN'S WORT (HYPERICUM PERFORATUM) ON CYTOCHROME P450 1A2 ACTIVITY IN PERFUSED RAT LIVER. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2011; 155:253-7. [DOI: 10.5507/bp.2011.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Wakuda H, Nejime N, Tada Y, Kagota S, Fahmi OA, Umegaki K, Yamada S, Shinozuka K. A novel method using confocal laser scanning microscopy for sensitive measurement of P-glycoprotein-mediated transport activity in Caco-2 cells. ACTA ACUST UNITED AC 2011; 63:1015-21. [PMID: 21718284 DOI: 10.1111/j.2042-7158.2011.01294.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this study was to use time-lapse confocal laser scanning microscopy to establish a more sensitive and specific method for evaluating P-glycoprotein activity in Caco-2 cells. METHODS The change in the fluorescence of residual rhodamine 123 at the apical and central regions of Caco-2 cells was measured in the presence of digoxin or St John's wort by using time-lapse confocal laser scanning microscopy. The data were compared with measurements made using conventional techniques, a fluorescence microplate reader and a fluorescence microscope. KEY FINDINGS The percentage decrease of rhodamine 123 caused by 10 µm digoxin or 0.1 µg/ml St John's wort was significantly larger in the apical region of the Caco-2 cell than in the central region or in the whole cell. The digoxin-induced inhibition in the apical region as measured by time-lapse confocal laser scanning microscopy was greater than that measured in the whole cell by a microplate reader or a fluorescence microscope. CONCLUSIONS The assay of residual rhodamine 123 in the apical region of Caco-2 cells by confocal laser scanning microscopy was more sensitive than the conventional methods using a microplate reader or fluorescence microscopy. It will be a valuable screening tool for studying both the inhibition and induction of P-glycoprotein activity.
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Affiliation(s)
- Hirokazu Wakuda
- Department of Pharmacology, School of Pharmacy and Pharmaceutical Sciences, Mukogawa Women's University, Nishinomiya, Japan
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Klemow K, Bartlow A, Crawford J, Kocher N, Shah J, Ritsick M. Medical Attributes of St. John's Wort (Hypericum perforatum). OXIDATIVE STRESS AND DISEASE 2011. [DOI: 10.1201/b10787-12] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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QIU W, LIU CX, JU Y, ZHANG HY. Pharmacokinetic Interaction of Plant Preparations with Chemical Drugs. Chin J Nat Med 2010. [DOI: 10.3724/sp.j.1009.2010.00137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Shord SS, Shah K, Lukose A. Drug-botanical interactions: a review of the laboratory, animal, and human data for 8 common botanicals. Integr Cancer Ther 2010; 8:208-27. [PMID: 19815591 DOI: 10.1177/1534735409340900] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Many Americans use complementary and alternative medicine (CAM) to prevent or alleviate common illnesses, and these medicines are commonly used by individuals with cancer.These medicines or botanicals share the same metabolic and transport proteins, including cytochrome P450 enzymes (CYP), glucuronosyltransferases (UGTs), and P-glycoprotein (Pgp), with over-the-counter and prescription medicines increasing the likelihood of drug-botanical interactions.This review provides a brief description of the different proteins, such as CYPs, UGTs, and Pgp.The potential effects of drug-botanical interactions on the pharmacokinetics and pharmacodynamics of the drug or botanical and a summary of the more common models used to study drug metabolism are described.The remaining portion of this review summarizes the data extracted from several laboratory, animal, and clinical studies that describe the metabolism, transport, and potential interactions of 8 selected botanicals. The 8 botanicals include black cohosh, Echinacea, garlic, Gingko biloba, green tea, kava, milk thistle, and St John's wort; these botanicals are among some of the more common botanicals taken by individuals with cancer.These examples are included to demonstrate how to interpret the different studies and how to use these data to predict the likelihood of a clinically significant drug-botanical interaction.
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Affiliation(s)
- Stacy S Shord
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA.
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Lei HP, Yu XY, Xie HT, Li HH, Fan L, Dai LL, Chen Y, Zhou HH. Effect of St. John’s wort supplementation on the pharmacokinetics of bupropion in healthy male Chinese volunteers. Xenobiotica 2010; 40:275-81. [DOI: 10.3109/00498250903509383] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Borrelli F, Izzo AA. Herb-drug interactions with St John's wort (Hypericum perforatum): an update on clinical observations. AAPS JOURNAL 2009; 11:710-27. [PMID: 19859815 DOI: 10.1208/s12248-009-9146-8] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Accepted: 09/21/2009] [Indexed: 12/15/2022]
Abstract
St John's wort (SJW) extracts, prepared from the aerial parts of Hypericum perforatum, contain numerous pharmacologically active ingredients, including naphthodianthrones (e.g., hypericin and its derivatives), phloroglucinols derivatives (e.g., hyperforin, which inhibits the reuptake of a number of neurotransmitters, including serotonin), and flavonoids. Such extracts are widely used for the treatment of mild-to-moderate depression. As a monotherapy, SJW has an encouraging safety profile. However, relevant and, in some case, life-threatening interactions have been reported, particularly with drugs which are substrate of cytochrome P450 and/or P-glycoprotein. Well-documented SJW interactions include (1) reduced blood cyclosporin concentration, as suggested by multiple case reports as well as by clinical trials, (2) serotonin syndrome or lethargy when SJW was given with serotonin reuptake inhibitors, (3) unwanted pregnancies in women while using oral contraceptives and SJW, and (4) reduced plasma drug concentration of antiretroviral (e.g., indinavir, nevirapine) and anticancer (i.e., irinotecan, imatinib) drugs. Hyperforin, which is believed to contribute to the antidepressant action of St John's wort, is also strongly suspected to be responsible of most of the described interactions.
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Affiliation(s)
- Francesca Borrelli
- Department of Experimental Pharmacology, University of Naples Federico II, Via D. Montesano 49, 80131, Naples, Italy.
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Effects of Dietary Factors on Drug Transport and Metabolism: The Impact on Dosage Guidelines in Transplant Patients. Clin Pharmacol Ther 2009; 85:439-43. [DOI: 10.1038/clpt.2008.303] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Hess S, De Geest S, Halter K, Dickenmann M, Denhaerynck K. Prevalence and correlates of selected alternative and complementary medicine in adult renal transplant patients. Clin Transplant 2009; 23:56-62. [DOI: 10.1111/j.1399-0012.2008.00901.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tomlinson B, Hu M, Lee VWY. In vivoassessment of herb–drug interactions: Possible utility of a pharmacogenetic approach? Mol Nutr Food Res 2008; 52:799-809. [DOI: 10.1002/mnfr.200700454] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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NOWACK RAINER. Review Article: Cytochrome P450 enzyme, and transport protein mediated herb–drug interactions in renal transplant patients: Grapefruit juice, St John's Wort – and beyond! (Review Article). Nephrology (Carlton) 2008; 13:337-47. [DOI: 10.1111/j.1440-1797.2008.00940.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Schwarz UI, Hanso H, Oertel R, Miehlke S, Kuhlisch E, Glaeser H, Hitzl M, Dresser GK, Kim RB, Kirch W. Induction of intestinal P-glycoprotein by St John's wort reduces the oral bioavailability of talinolol. Clin Pharmacol Ther 2007; 81:669-78. [PMID: 17392718 DOI: 10.1038/sj.clpt.6100191] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
St John's wort (SJW) is known to induce cytochrome P450 (CYP) 3A4 and P-glycoprotein through pregnane X-receptor activation. Our study evaluated the effects of long-term SJW administration on oral and intravenous pharmacokinetics of the nonmetabolized in vivo probe of P-glycoprotein, talinolol, in relation to intestinal P-glycoprotein expression. In a controlled, randomized study (N=9), the pharmacokinetics of oral (50 mg) and intravenous talinolol (30 mg) was determined before and after 12 days SJW (900 mg daily, Jarsin 300). Duodenal biopsies were taken and MDR1 genotypes assessed. SJW reduced the oral talinolol bioavailability by 25% (P=0.049) compared with water control. A 93% increase in oral clearance (P=0.177) and a 31% reduction in area under the serum concentration time curve (AUC; P=0.030) were observed. Renal and nonrenal clearance (CLNR), elimination half-life, peak serum drug concentration (Cmax), and time to reach Cmax were not significantly altered. After intravenous talinolol, SJW affected only CLNR (35% increase compared with water, P=0.006). SJW increased MDR1 messenger ribonucleic acid (mRNA) as well as P-glycoprotein levels in the duodenal mucosa. Subjects with the combined MDR1 genotype comprising 1236C>T, 2677G>T/A, and 3435C>T polymorphisms had lower intestinal MDR1 mRNA levels and displayed an attenuated inductive response to SJW as assessed by talinolol disposition. Long-term SJW decreased talinolol AUC with a corresponding increase in intestinal MDR1 expression, suggesting that SJW has a major inductive effect on intestinal P-glycoprotein. Interestingly, the magnitude of induction appeared to be affected by MDR1 genotype.
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Affiliation(s)
- U I Schwarz
- Medical Faculty, Institute of Clinical Pharmacology, Technical University Dresden, Dresden, Germany.
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Murakami Y, Tanaka T, Murakami H, Tsujimoto M, Ohtani H, Sawada Y. Pharmacokinetic modelling of the interaction between St John's wort and ciclosporin A. Br J Clin Pharmacol 2007; 61:671-6. [PMID: 16722827 PMCID: PMC1885115 DOI: 10.1111/j.1365-2125.2006.02606.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIMS St John's wort (SJW) decreases the blood concentration of ciclosporin A (CsA), which may result in allograft rejection. In addition, the time course of this interaction is not parallel with the administration of SJW. We aimed to develop a pharmacokinetic model to predict the time profile of blood CsA concentrations during and after the intake of SJW. METHODS We developed a pharmacokinetic model incorporating turnover of detoxicating proteins, with the assumption that the amount of detoxicating proteins is in inverse proportion to the ratio of trough blood concentration to daily dose (C/D ratio) of CsA. First, we collected time profiles of blood CsA during and after the intake of SJW from the literature. Next, we analysed the relationship between D/C ratio and the daily dose of SJW at steady state. Subsequently, the developed model was simultaneously fitted to the time profiles of C/D ratios by using a nonlinear least-squares method to obtain model parameters. RESULTS The model analysis revealed that the induction of the detoxicating proteins by SJW was saturable with an elimination rate constant of the detoxicating proteins (ke) of 4.72 month(-1). Elimination half-life of the detoxicating proteins calculated from the ke value was 4.4 days, suggesting that the dose of CsA should be carefully monitored for up to 2 weeks after the cessation of SJW intake. CONCLUSIONS The present model may provide additional information for use in identifying optimal dosage regimens of CsA during and after the intake of SJW to prevent an adverse drug interaction between CsA and SJW.
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Affiliation(s)
- Yuichi Murakami
- Department of Medico-Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kyushu University3-1-1 Maidashi, Higashi-ku, Fukuoka 812–8582, Japan
| | - Tomoaki Tanaka
- Department of Medico-Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kyushu University3-1-1 Maidashi, Higashi-ku, Fukuoka 812–8582, Japan
| | - Hideyasu Murakami
- Department of Medico-Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kyushu University3-1-1 Maidashi, Higashi-ku, Fukuoka 812–8582, Japan
| | - Masayuki Tsujimoto
- Department of Medico-Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kyushu University3-1-1 Maidashi, Higashi-ku, Fukuoka 812–8582, Japan
| | - Hisakazu Ohtani
- Department of Medico-Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kyushu University3-1-1 Maidashi, Higashi-ku, Fukuoka 812–8582, Japan
| | - Yasufumi Sawada
- Department of Drug Informatics, Graduate School of Pharmaceutical Sciences, The University of Tokyo7-3-1 Hongo, Bunkyo-Ku, Tokyo 113-0033, Japan
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Tomás-Guillén E, Farriols-Danés A, Cantarell-Aixendri C, Carlos Juárez-Giménez J. Interacciones entre plantas medicinales y fármacos inmunodepresores. Med Clin (Barc) 2006; 127:177-84. [PMID: 16834954 DOI: 10.1157/13090706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Elena Tomás-Guillén
- Servicio de Farmacia, Hospital Universitario Vall d'Hebron, Barcelona, España
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Pal D, Mitra AK. MDR- and CYP3A4-mediated drug–herbal interactions. Life Sci 2006; 78:2131-45. [PMID: 16442130 DOI: 10.1016/j.lfs.2005.12.010] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2005] [Accepted: 12/07/2005] [Indexed: 12/19/2022]
Abstract
According to recent epidemiological reports, almost 40% of American population use complimentary and alternative medicine (CAM) during their lifetime. Patients detected with HIV or cancer often consume herbal products especially St. John's wort (SJW) for antidepressants in combination with prescription medicines. Such self-administered herbal products along with prescribed medicines raise concerns of therapeutic activity due to possible drug-herbal interactions. P-glycoprotein (P-gp) and cytochrome P450 3A4 (CYP3A4) together constitute a highly efficient barrier for many orally absorbed drugs. Available literature, clinical reports and in vitro studies from our laboratory indicate that many drugs and herbal active constituents are substrates for both P-gp and CYP3A4. Results from clinical studies and case reports indicate that self-administered SJW reduce steady state plasma concentrations of amitriptyline, cyclosporine, digoxin, fexofenadine, amprenavir, indonavir, lopinavir, ritonavir, saquinavir, benzodiazepines, theophyline, irinotecan, midazolan and warfarin. This herbal agent has been also reported to cause bleeding and unwanted pregnancies when concomitantly administered with oral contraceptives. Most of these medicinal agents and SJW are substrates for P-gp and/or CYP3A4. In vitro studies from our laboratory suggest that short-term exposure with pure herbal agents such as hypericin, kaempferol and quercetin or extract of SJW resulted in higher uptake or influx of ritonavir and erythromycin. Hypericin, kaempferol and quercetin also caused a remarkable inhibition of cortisol metabolism with the percent intact cortisol values of 64.58%, 89.6% and 90.1%, respectively, during short-term in vitro experiments. Conversely, long-term exposure of herbal agents (hyperforin, kaempferol and quercetin) showed enhanced expression of CYP3A4 mRNA in Caco-2 cells. In another study, we observed that long-term exposure of hypericin, kaempferol, quercetin and silibinin resulted in higher MDR-1 mRNA expression in Caco-2 cells. Therefore, herbs can pharmacokinetically act as inhibitors or inducers. Medicinal agents that are substrates P-gp-mediated efflux and/or CYP-mediated metabolism are likely to be potential candidates for drug-herbal interactions. The duration of exposure of cells/healthy volunteers/animals to herbals appears to be critical for drug-herbal interaction. An increase in plasma drug concentration is possible during concomitant administration of SJW and prescribed drugs. In contrast, prolonged intake of herbal supplement followed by drug administration may result in subtherapeutic concentrations. Therefore, clinical implications of such drug herbal interactions depend on a variety of factors such as dose, frequency and timing of herbal intake, dosing regimen, route of drug administration and therapeutic range. In vitro screening techniques will play a major role in identifying possible herb-drug interactions and thus create a platform for clinical studies to emerge. Mechanisms of drug-herbal interaction have been discussed in this review article.
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Affiliation(s)
- Dhananjay Pal
- School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO 64110-2499, USA
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Abstract
This review seeks to apply a decision-making algorithm to establish whether clinical pharmacokinetic monitoring (CPM) of sirolimus (rapamycin) in solid organ transplantation is indicated in specific patient populations. The need for CPM of sirolimus, although a regulatory requirement in Europe, has not yet been firmly established in North America and other parts of the world. Sirolimus has demonstrated immunosuppressive efficacy in renal, pancreatic islet cell, liver and heart transplant recipients. The pharmacological response of immunosuppressive therapy with sirolimus cannot be readily evaluated; however, a relationship between trough blood sirolimus concentrations, area under the plasma concentration-time curve (AUC) and the incidence of rejection has been proposed. Furthermore, sirolimus can be measured in whole blood by several assays--high-performance liquid chromatography with detection by tandem mass spectrometry, or with ultraviolet detection, radioreceptor assay or microparticle enzyme immunoassay. Both experimental animal and clinical data suggest that adverse events and their associated severity are correlated with blood concentrations. To prevent rejection and minimise toxicity, a therapeutic range of 4-12 microg/L (measured via chromatographic assays) is recommended when sirolimus is used in conjunction with ciclosporin. If ciclosporin therapy is discontinued, a target trough range of 12-20 microg/L is recommended. Sirolimus pharmacokinetics display large inter- and intrapatient variability, which may change in specific patient populations due to disease states or concurrent immunosuppressants or other interacting drugs. Due to the long half-life of sirolimus, dosage adjustments would ideally be based on trough levels obtained more than 5-7 days after initiation of therapy or dosage change. Once the initial dose titration is complete, monitoring sirolimus trough concentrations weekly for the first month and every 2 weeks for the second month appears to be appropriate. After the first 2 months of dose titration, routine CPM of sirolimus is not necessary in all patients, but may be warranted to achieve target concentrations in certain populations of patients, but the frequency of further monitoring remains to be determined and should be individualised.
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Affiliation(s)
- Sunita Bond Stenton
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
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Zhou S, Huang M, Xu A, Yang H, Duan W, Paxton JW. Prediction of herb-drug metabolic interactions: a simulation study. Phytother Res 2005; 19:464-71. [PMID: 16114078 DOI: 10.1002/ptr.1559] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In vitro and in vivo studies have indicated that the induction or inhibition of cytochrome P450 (CYP) is one of the major mechanisms for some clinically important pharmacokinetic herb-drug interactions. An attempt was made to simulate the effects of herbal preparation with single or multiple CYP-inhibiting constituents on the area of the plasma concentration-time curve (AUC) of coadministered drug that was either a low clearance drug by intravenous (i.v.) injection or a high clearance drug by oral route. Our simulation studies indicated that the expected increase (Rc) in the AUC of the coadministered drug by inhibiting herbal constituent(s) was dependent on the route of administration. For low clearance drug by i.v. injection, Rc was generally determined by inhibition constant (Ki), unbound inhibitor concentration ([I]), hepatic fraction (fh), number of inhibitory herbal constituents (n) and metabolic pathway fraction in hepatic metabolism (fm), while Rc for a high clearance drug by oral route, Rc was determined by Ki, [I], n and fm. By varying these parameters, Rc changed accordingly. It appeared likely to predict a herb-drug metabolic interaction, if the inhibiting herbal constituents could be quantitatively determined. However, many herb- and drug-related factors may cause difficulties with the prediction, and thus in vivo animal and human studies are always necessary.
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Affiliation(s)
- Shufeng Zhou
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore.
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Nowack R, Nowak B. Herbal teas interfere with cyclosporin levels in renal transplant patients. Nephrol Dial Transplant 2005; 20:2554-6. [PMID: 16046518 DOI: 10.1093/ndt/gfi003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
In the developing world, up to 80% of the population uses traditional medicine for primary health care. In industrialized countries, adaptations of traditional medicine, termed "complementary" or "alternative" medicine (CAM), are used by a growing number of patients for preventive or palliative care. However, alternative medicine (AM) may be an important risk for the development of acute and chronic kidney injury because of several factors: nonconventional preparations rarely meet the required essential standards of consistency in composition and biological activity; many of these products contain undisclosed over-the-counter or prescription drugs or can be adulterated with hormones and glandular extracts; herbal preparations can be contaminated by pesticides and heavy metals; and because of errors in plant identification and confusing terminology, opportunities for mistakes and deliberate substitution can occur. Furthermore, there is a lack of reports of adverse events and drug interactions because of a lack of professional surveillance, and specific data on systemic and kidney toxicity are not easily available. Kidney injury/kidney syndromes caused by AM consist of acute tubular necrosis/toxicity (eg, Fanconi's syndrome), acute interstitial nephritis, papillary necrosis, hypertension, kidney stones, urinary retention, chronic tubulointerstitial nephritis with fibrosis, urinary tract carcinoma, and acute rejection of the kidney transplant. To improve the care for patients using AM, extension of physicians' knowledge about its possible hazards and toxicity is essential. This review deals with acute and chronic kidney toxicity caused by animal-, plant-, and mineral-based, nonconventional medicine and kidney failure caused by drug interactions with AM.
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Affiliation(s)
- Conny R D Colson
- Department of Nephrology, University of Antwerp, Antwerp, Belgium
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Abstract
Herbal medicines are mixtures of more than one active ingredient. The multitude of pharmacologically active compounds obviously increases the likelihood of interactions taking place. Hence, the likelihood of herb-drug interactions is theoretically higher than drug-drug interactions, if only because synthetic drugs usually contain single chemical entities. Case reports and clinical studies have highlighted the existence of a number of clinically important interactions, although cause-and-effect relationships have not always been established. Herbs and drugs may interact either pharmacokinetically or pharmacodynamically. Through induction of cytochrome P450 enzymes and/or P-glycoprotein, some herbal products (e.g. St John's wort) have been shown to lower the plasma concentration (and/or the pharmacological effect) of a number of conventional drugs, including cyclosporine, indinavir, irinotecan, nevirapine, oral contraceptives and digoxin. The majority of such interactions involves medicines that require regular monitoring of blood levels. To date there is less evidence relating to the pharmacodynamic interaction. However, for many of the interactions discussed here, the understanding of the mechanisms involved is incomplete. Taking herbal agents may represent a potential risk to patients under conventional pharmacotherapy.
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Affiliation(s)
- Angelo A Izzo
- Department of Experimental Pharmacology, University of Naples Federico II, via D. Montesano 49, 80131 Naples, Italy.
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Kawaguchi A, Ohmori M, Tsuruoka SI, Nishiki K, Harada K, Miyamori I, Yano RI, Nakamura T, Masada M, Fujimura A. Drug interaction between St John's Wort and quazepam. Br J Clin Pharmacol 2005; 58:403-10. [PMID: 15373933 PMCID: PMC1884612 DOI: 10.1111/j.1365-2125.2004.02171.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
AIM St John's Wort (SJW) enhances CYP3A4 activity and decreases blood concentrations of CYP3A4 substrates. In this study, the effects of SJW on a benzodiazepine hypnotic, quazepam, which is metabolized by CYP3A4, were examined. METHODS Thirteen healthy subjects took a single dose of quazepam 15 mg after treatment with SJW (900 mg day(-1)) or placebo for 14 days. The study was performed in a randomized, placebo-controlled, cross-over design with an interval of 4 weeks between the two treatments. Blood samples were obtained during a 48 h period and urine was collected for 24 h after each dose of quazepam. Pharmacodynamic effects were determined using visual analogue scales (VAS) and the digit symbol substitution test (DSST) on days 13 and 14. RESULTS SJW decreased the plasma quazepam concentration. The Cmax and AUC(0-48) of quazepam after SJW were significantly lower than those after placebo [Cmax; -8.7 ng ml(-1) (95% confidence interval (CI) -17.1 to -0.2), AUC0-48; -55 ng h ml(-1) (95% CI -96 to -15)]. The urinary ratio of 6beta-hydroxycortisol to cortisol, which reflects CYP3A4 activity, also increased after dosing with SJW (ratio; 2.1 (95%CI 0.85-3.4)). Quazepam, but not SJW, produced sedative-like effects in the VAS test (drowsiness; P < 0.01, mental slowness; P < 0.01, calmness; P < 0.05, discontentment; P < 0.01). On the other hand, SJW, but not quazepam impaired psychomotor performance in the DSST test. SJW did not influence the pharmacodynamic profile of quazepam. CONCLUSIONS These results suggest that SJW decreases plasma quazepam concentrations, probably by enhancing CYP3A4 activity, but does not influence the pharmacodynamic effects of the drug.
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Affiliation(s)
| | - Masami Ohmori
- Department of Clinical Pharmacology, Jichi Medical SchoolJapan
| | | | - Kenta Nishiki
- Department of Clinical Pharmacology, Jichi Medical SchoolJapan
| | - Kenichi Harada
- Department of Clinical Pharmacology, Jichi Medical SchoolJapan
| | | | - Ryo-ichi Yano
- Departments of Hospital Pharmacy, Fukui Medical UniversityJapan
| | | | - Mikio Masada
- Departments of Hospital Pharmacy, Fukui Medical UniversityJapan
| | - Akio Fujimura
- Department of Clinical Pharmacology, Jichi Medical SchoolJapan
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Abstract
P-glycoprotein (Pgp) is a 170 kDa phosphorylated glycoprotein encoded by human MDR1 gene. It is responsible for the systemic disposition of numerous structurally and pharmacologically unrelated lipophilic and amphipathic drugs, carcinogens, toxins, and other xenobiotics in many organs, such as the intestine, liver, kidney, and brain. Like cytochrome P450s (CYP3A4), Pgp is vulnerable to inhibition, activation, or induction by herbal constituents. This was demonstrated by using an ATPase assay, purified Pgp protein or intact Pgp-expressing cells, and proper probe substrates and inhibitors. Curcumin, ginsenosides, piperine, some catechins from green tea, and silymarin from milk thistle were found to be inhibitors of Pgp, while some catechins from green tea increased Pgp-mediated drug transport by heterotropic allosteric mechanism, and St. John's wort induced the intestinal expression of Pgp in vitro and in vivo. Some components (e.g., bergamottin and quercetin) from grapefruit juice were reported to modulate Pgp activity. Many of these herbal constituents, in particular flavonoids, were reported to modulate Pgp by directly interacting with the vicinal ATP-binding site, the steroid-binding site, or the substrate-binding site. Some herbal constituents (e.g., hyperforin and kava) were shown to activate pregnane X receptor, an orphan nuclear receptor acting as a key regulator of MDR1 and many other genes. The inhibition of Pgp by herbal constituents may provide a novel approach for reversing multidrug resistance in tumor cells, whereas the stimulation of Pgp expression or activity has implication for chemoprotective enhancement by herbal medicines. Certain natural flavonols (e.g., kaempferol, quercetin, and galangin) are potent stimulators of the Pgp-mediated efflux of 7,12-dimethylbenz(a)-anthracene (a carcinogen). The modulation of Pgp activity and expression by these herb constituents may result in altered absorption and bioavailability of drugs that are Pgp substrates. This is exemplified by increased oral bioavailability of phenytoin and rifampin by piperine and decreased bioavailability of indinavir, tacrolimus, cyclosporine, digoxin, and fexofenadine by coadministered St. John's wort. However, many of these drugs are also substrates of CYP3A4. Thus, the modulation of intestinal Pgp and CYP3A4 represents an important mechanism for many clinically important herb-drug interactions. Further studies are needed to explore the relative role of Pgp and CYP3A4 modulation by herbs and the mechanism for the interplay of these two important proteins in herb-drug interactions.
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Affiliation(s)
- Shufeng Zhou
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore.
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Leather HL. Drug interactions in the hematopoietic stem cell transplant (HSCT) recipient: what every transplanter needs to know. Bone Marrow Transplant 2004; 33:137-52. [PMID: 14676788 DOI: 10.1038/sj.bmt.1704316] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Pharmacokinetic drug interactions among hematopoietic stem cell transplant recipients can result in either increases in serum concentrations of medications, which may lead to enhanced toxicity; or reduced serum concentrations, which can lead to treatment failure and the emergence of post transplant complications. The use of drugs that have a narrow therapeutic index, such as cyclosporine/tacrolimus (calcineurin inhibitors), increases the significance of these interactions when they occur. This report will review the clinical data evaluating the drug interactions of relevance to HSCT clinical practice, focusing on the pharmacokinetic interactions, and provides recommendations for managing these interactions to avoid both toxicity and treatment failure.
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Affiliation(s)
- H L Leather
- University of Florida, 1600 SW Archer Road, Box 100316, Gainesville, FL 32610, USA.
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Bielory L. Complementary and alternative interventions in asthma, allergy, and immunology. Ann Allergy Asthma Immunol 2004; 93:S45-54. [PMID: 15330011 DOI: 10.1016/s1081-1206(10)61486-x] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To review which herbs are most commonly used as complementary and alternative medicine (CAM) for treatment of asthma, allergy, and immunologic conditions. DATA SOURCES A review of the literature was performed using the PubMed and OVID databases searching the keywords asthma, allergy, and CAM to identify studies published between 1980 and 2003 that focused on Echinacea (Echinacea augustifolia, Echinacea pallida, and Echinacea purpurea); garlic (Allium); angelica; chamomile; ephedra; gingko; grape seed extract; licorice root (Glycyrrhiza); St. John's wort (Hypericum); kava kava (Piper); peppermint oil and leaf (Mentha); stinging nettle (Urtica); and ginseng (Panax) published in the English and German literature. STUDY SELECTION Studies included in vitro and in vivo clinical trials and case reports selected according to the expert opinion of the author. RESULTS Echinacea is one of the most common herbs used to treat symptoms of the "common cold" or upper respiratory tract allergies. Although no common drug interactions have been reported, there is a risk of hepatotoxicity, exacerbation of allergies and asthma, and anaphylactic reactions. Garlic is primarily used for cardiovascular health and relief of cough, colds, and rhinitis. Adverse effects commonly include gastrointestinal disturbances, change in body odor through the sweat and breath, and rarely allergic reactions or hypoglycemia. Other CAM agents, including angelica, German chamomile flower, ephedra, gingko, grape seed extract, licorice root, St. John's wort, kava kava rhizome, peppermint, stinging nettle, and ginseng, are also associated with significant adverse effects. CONCLUSION The specialty of allergy and immunology has seen the second largest increase in the popularity of CAM (second only to practitioners who treat lower back pain). Almost all of the CAM interventions have displayed adverse effects, usually in the form of a hypersensitivity reaction. Allergists and clinical immunologists need to become more knowledgeable about CAM so that they can inform patients about the use and possible abuse of these modalities.
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Affiliation(s)
- Leonard Bielory
- Department of Medicine, Pediatrics, and Ophthalmology, Division of Allergy, Immunology, and Rheumatology, UMDNJ-New Jersey Medical School, Newark, New Jersey 07103, USA.
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Sparreboom A, Cox MC, Acharya MR, Figg WD. Herbal remedies in the United States: potential adverse interactions with anticancer agents. J Clin Oncol 2004; 22:2489-503. [PMID: 15197212 DOI: 10.1200/jco.2004.08.182] [Citation(s) in RCA: 274] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Interest in the use of herbal products has grown dramatically in the Western world. Recent estimates suggest an overall prevalence for herbal preparation use of 13% to 63% among cancer patients. With the narrow therapeutic range associated with most anticancer drugs, there is an increasing need for understanding possible adverse drug interactions in medical oncology. METHODS In this article, a literature overview is provided of known or suspected interactions of the 15 best-selling herbs in the United States with conventional allopathic therapies for cancer. RESULTS Herbs with the potential to significantly modulate the activity of drug-metabolizing enzymes (notably cytochrome p450 isozymes) and/or the drug transporter P-glycoprotein include garlic (Allium sativum), ginkgo (Ginkgo biloba), echinacea (Echinacea purpurea), ginseng (Panax ginseng), St John' s wort (Hypericum perforatum), and kava (Piper methysticum). All of these products participate in potential pharmacokinetic interactions with anticancer drugs. CONCLUSION It is suggested that health care professionals and consumers should be aware of the potential for adverse interactions with these herbs, question their patients on their use of them, especially among patients whose disease is not responding to treatments as expected, and urge patients to avoid herbs that could confound their cancer care.
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Affiliation(s)
- Alex Sparreboom
- Clinical Pharmacology Research Core, Medical Oncology Clinical Research Unit, National Cancer Institute, Bethesda, Maryland 20892, USA.
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Abstract
There is a worldwide increasing use of herbs which are often administered in combination with therapeutic drugs, raising the potential for herb-drug interactions. St John's wort (Hypericum perforatum) is one of the most commonly used herbal antidepressants. A literature search was performed using Medline (via Pubmed), Biological Abstracts, Cochrane Library, AMED, PsycINFO and Embase (all from their inception to September 2003) to identify known drug interaction with St John's wort. The available data indicate that St John's wort is a potent inducer of CYP 3A4 and P-glycoprotein (PgP), although it may inhibit or induce other CYPs, depending on the dose, route and duration of administration. Data from human studies and case reports indicate that St John's wort decreased the blood concentrations of amitriptyline, cyclosporine, digoxin, fexofenadine, indinavir, methadone, midazolam, nevirapine, phenprocoumon, simvastatin, tacrolimus, theophylline and warfarin, whereas it did not alter the pharmacokinetics of carbamazepine, dextromethorphan, mycophenolic acid and pravastatin. St John's wort decreased the plasma concentration of the active metabolite SN-38 in cancer patients receiving irinotecan treatment. St John's wort did not alter the pharmacokinetics of tolbutamide, but increased the incidence of hypoglycaemia. Several cases have been reported that St John's wort decreased cyclosporine blood concentration leading to organ rejection. St John's wort caused breakthrough bleeding and unplanned pregnancies when used concomitantly with oral contraceptives. It also caused serotonin syndrome when coadministered with selective serotonin-reuptake inhibitors (e.g. sertaline and paroxetine). Both pharmacokinetic and pharmacodynamic components may play a role in these interactions. Because the potential interaction of St John's wort with other drugs is a major safety concern, additional systematic research on herb-drug interactions and appropriate regulation in herbal safety and efficacy is needed.
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Affiliation(s)
- Shufeng Zhou
- Department of Pharmacy, Faculty of Science, National University of Singapore.
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Morimoto T, Kotegawa T, Tsutsumi K, Ohtani Y, Imai H, Nakano S. Effect of St. John's wort on the pharmacokinetics of theophylline in healthy volunteers. J Clin Pharmacol 2004; 44:95-101. [PMID: 14681347 DOI: 10.1177/0091270003261496] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study was to investigate the effect of St. John's wort (SJW, Hypericum perforatum) on the pharmacokinetics of theophylline in healthy volunteers. Twelve healthy Japanese male volunteers participated in this randomized, open-labeled, crossover study. The subjects took an SJW caplet (300 mg) three times a day for 15 days. On day 14, they received a single oral dose of 400 mg of theophylline. They took the same dose of theophylline without SJW treatment on another occasion. Plasma and urine samples were obtained during a 48-hour period after theophylline administration. Theophylline concentrations in plasma and urine, as well as the major metabolites (13U, 1U, 3X) in urine, were measured. SJW caused no significant changes in the pharmacokinetics of theophylline in plasma. SJW administration tended to increase the ratio of 1U/the total amount excreted in urine. However, no changes in the ratio of unchanged theophylline, 13U, and 3X were observed. It is unlikely that the effect of 15 days of treatment with SJW on CYPs is sufficient to cause a change in plasma theophylline concentrations.
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Affiliation(s)
- Takuya Morimoto
- Department of Clinical Pharmacology and Therapeutics, Oita Medical University, Japan
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Abstract
Metabolic food-drug interactions occur when the consumption of a particular food modulates the activity of a drug-metabolising enzyme system, resulting in an alteration of the pharmacokinetics of drugs metabolised by that system. A number of these interactions have been reported. Foods that contain complex mixtures of phytochemicals, such as fruits, vegetables, herbs, spices and teas, have the greatest potential to induce or inhibit the activity of drug-metabolising enzymes, although dietary macroconstituents (i.e. total protein, fat and carbohydrate ratios, and total energy intake) can also have effects. Particularly large interactions may result from the consumption of herbal dietary supplements. Cytochrome P450 (CYP) 3A4 appears to be especially sensitive to dietary effects, as demonstrated by reports of potentially clinically important interactions involving orally administered drugs that are substrates of this enzyme. For example, interactions of grapefruit juice with cyclosporin and felodipine, St John's wort with cyclosporin and indinavir, and red wine with cyclosporin, have the potential to require dosage adjustment to maintain drug concentrations within their therapeutic windows. The susceptibility of CYP3A4 to modulation by food constituents may be related to its high level of expression in the intestine, as well as its broad substrate specificity. Reported ethnic differences in the activity of this enzyme may be partly due to dietary factors. Food-drug interactions involving CYP1A2, CYP2E1, glucuronosyltransferases and glutathione S-transferases have also been documented, although most of these interactions are modest in magnitude and clinically relevant only for drugs that have a narrow therapeutic range. Recently, interactions involving drug transporters, including P-glycoprotein and the organic anion transporting polypeptide, have also been identified. Further research is needed to determine the scope, magnitude and clinical importance of food effects on drug metabolism and transport.
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Affiliation(s)
- Robert Z Harris
- Department of Pharmacokinetics and Drug Metabolism, Amgen Inc, Thousand Oaks, California 91320-1799, USA.
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Hammerness P, Basch E, Ulbricht C, Barrette EP, Foppa I, Basch S, Bent S, Boon H, Ernst E. St John's wort: a systematic review of adverse effects and drug interactions for the consultation psychiatrist. PSYCHOSOMATICS 2003; 44:271-82. [PMID: 12832592 DOI: 10.1176/appi.psy.44.4.271] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
St. John's wort is an herb commonly used in Europe for decades and more recently the topic of scientific investigation in this country. St. John's wort has been found more effective than placebo and equally as effective as tricyclic antidepressants in the short-term management of mild-to-moderate depression. Comparisons to selective serotonin reuptake inhibitors have provided equivocal data. While it is generally well tolerated in clinical use, there is accumulating evidence of significant interactions with drugs. This evidence-based presentation of the literature includes a brief description of pharmacodynamics and clinical applications, followed by a systematic review of adverse effects, toxicity, and drug interactions.
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Abstract
A resurgence in the use of medical herbs in the Western world, and the co-use of modern and traditional therapies is becoming more common. Thus there is the potential for both pharmacokinetic and pharmacodynamic herb-drug interactions. For example, systems such as the cytochrome P450 (CYP) may be particularly vulnerable to modulation by the multiple active constituents of herbs, as it is well known that the CYPs are subject to induction and inhibition by exposure to a wide variety of xenobiotics. Using in vitro, in silico, and in vivo approaches, many herbs and natural compounds isolated from herbs have been identified as substrates, inhibitors, and/or inducers of various CYP enzymes. For example, St. John's wort is a potent inducer of CYP3A4, which is mediated by activating the orphan pregnane X receptor. It also contains ingredients that inhibit CYP1A2, CYP2C9, CYP2C19, CYP2D6, and CYP3A4. Many other common medicinal herbs also exhibited inducing or inhibiting effects on the CYP system, with the latter being competitive, noncompetitive, or mechanism-based. It appears that the regulation of CYPs by herbal products complex, depending on the herb type, their administration dose and route, the target organ and species. Due to the difficulties in identifying the active constituents responsible for the modulation of CYP enzymes, prediction of herb-drug metabolic interactions is difficult. However, herb-CYP interactions may have important clinical and toxicological consequences. For example, induction of CYP3A4 by St. John's wort may partly provide an explanation for the enhanced plasma clearance of a number of drugs, such as cyclosporine and innadivir, which are known substrates of CYP3A4, although other mechanisms including modulation of gastric absorption and drug transporters cannot be ruled out. In contrast, many organosulfur compounds, such as diallyl sulfide from garlic, are potent inhibitors of CYP2E1; this may provide an explanation for garlic's chemoproventive effects, as many mutagens require activation by CYP2E1. Therefore, known or potential herb-CYP interactions exist, and further studies on their clinical and toxicological roles are warranted. Given that increasing numbers of people are exposed to a number of herbal preparations that contain many constituents with potential of CYP modulation, high-throughput screening assays should be developed to explore herb-CYP interactions.
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Affiliation(s)
- Shufeng Zhou
- Department of Pharmacy, Faculty of Science, National University of Singapore, Republic of Singapore.
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