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Dai GX, Tan W, Shen Y, Lin D, Xu RA, Lin Q, Wei Z. Differential inhibition of sildenafil and macitentan on saxagliptin metabolism. Toxicol Appl Pharmacol 2024; 486:116934. [PMID: 38663673 DOI: 10.1016/j.taap.2024.116934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/16/2024] [Accepted: 04/15/2024] [Indexed: 04/29/2024]
Abstract
The development of diabetes mellitus (DM) is generally accompanied by erectile dysfunction (ED) and pulmonary arterial hypertension (PAH), which increases the use of combination drug therapy and the risk of drug-drug interactions. Saxagliptin for the treatment of DM, sildenafil for the treatment of ED and PAH, and macitentan for the treatment of PAH are all substrates of CYP3A4, which indicates their potential involvement in drug-drug interactions. Therefore, we investigated potential pharmacokinetic interactions between saxagliptin and sildenafil/macitentan. We investigated this speculation both in vitro and in vivo, and explored the underlying mechanism using in vitro hepatic metabolic models and molecular docking assays. The results showed that sildenafil substantially inhibited the metabolism of saxagliptin by occupying the catalytic site of CYP3A4 in a competitive manner, leading to the alterations in the pharmacokinetic properties of saxagliptin in terms of increased maximum plasma concentration (Cmax), area under the plasma concentration-time curve from time 0 to 24 h (AUC(0-t)), area under the plasma concentration-time curve from time 0 extrapolated to infinite time (AUC(0-∞)), decreased clearance rate (CLz/F), and prolonged terminal half-life (t1/2). In contrast, a slight inhibition was observed in saxagliptin metabolism when concomitantly used with macitentan, as no pharmacokinetic parameters were altered, except for CLz/F. Thus, dosage adjustment of saxagliptin may be required in combination with sildenafil to achieve safe therapeutic plasma concentrations and reduce the risk of potential toxicity, but it is not necessary for co-administration with macitentan.
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Affiliation(s)
- Ge-Xin Dai
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325035, China
| | - Wei Tan
- The Third Affiliated Hospital of Chongqing Medical University (Gener Hospital), Chongqing 401120, China
| | - Yuxin Shen
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325035, China
| | - Dongdong Lin
- School of Pharmaceutical Science, Wenzhou Medical University, Wenzhou, Zhejiang 325035, China
| | - Ren-Ai Xu
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325035, China
| | - Qianmeng Lin
- Department of Oncology, Department of Pathology, NHC Key Laboratory of Cancer Proteomics & State Local Joint Engineering Laboratory for Anticancer Drugs, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
| | - Zhen Wei
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325035, China.
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Rigalli JP, Gagliardi A, Diester K, Bajraktari-Sylejmani G, Blank A, Burhenne J, Lenard A, Werntz L, Huppertz A, Münch L, Wendt JM, Sauter M, Haefeli WE, Weiss J. Extracellular Vesicles as Surrogates for the Regulation of the Drug Transporters ABCC2 (MRP2) and ABCG2 (BCRP). Int J Mol Sci 2024; 25:4118. [PMID: 38612927 PMCID: PMC11012658 DOI: 10.3390/ijms25074118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/02/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024] Open
Abstract
Drug efflux transporters of the ATP-binding-cassette superfamily play a major role in the availability and concentration of drugs at their site of action. ABCC2 (MRP2) and ABCG2 (BCRP) are among the most important drug transporters that determine the pharmacokinetics of many drugs and whose overexpression is associated with cancer chemoresistance. ABCC2 and ABCG2 expression is frequently altered during treatment, thus influencing efficacy and toxicity. Currently, there are no routine approaches available to closely monitor transporter expression. Here, we developed and validated a UPLC-MS/MS method to quantify ABCC2 and ABCG2 in extracellular vesicles (EVs) from cell culture and plasma. In this way, an association between ABCC2 protein levels and transporter activity in HepG2 cells treated with rifampicin and hypericin and their derived EVs was observed. Although ABCG2 was detected in MCF7 cell-derived EVs, the transporter levels in the vesicles did not reflect the expression in the cells. An analysis of plasma EVs from healthy volunteers confirmed, for the first time at the protein level, the presence of both transporters in more than half of the samples. Our findings support the potential of analyzing ABC transporters, and especially ABCC2, in EVs to estimate the transporter expression in HepG2 cells.
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Affiliation(s)
- Juan Pablo Rigalli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical Faculty Heidelberg, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (W.E.H.); (J.W.)
| | - Anna Gagliardi
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical Faculty Heidelberg, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (W.E.H.); (J.W.)
- Department of Food and Drug, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Klara Diester
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical Faculty Heidelberg, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (W.E.H.); (J.W.)
| | - Gzona Bajraktari-Sylejmani
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical Faculty Heidelberg, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (W.E.H.); (J.W.)
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical Faculty Heidelberg, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (W.E.H.); (J.W.)
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical Faculty Heidelberg, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (W.E.H.); (J.W.)
| | - Alexander Lenard
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical Faculty Heidelberg, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (W.E.H.); (J.W.)
| | - Lars Werntz
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical Faculty Heidelberg, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (W.E.H.); (J.W.)
| | - Andrea Huppertz
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical Faculty Heidelberg, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (W.E.H.); (J.W.)
- MVZ Diaverum Remscheid, Rosenhügelstraße 4a, 42859 Remscheid, Germany
| | - Lena Münch
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical Faculty Heidelberg, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (W.E.H.); (J.W.)
| | - Janica Margrit Wendt
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical Faculty Heidelberg, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (W.E.H.); (J.W.)
| | - Max Sauter
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical Faculty Heidelberg, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (W.E.H.); (J.W.)
| | - Walter Emil Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical Faculty Heidelberg, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (W.E.H.); (J.W.)
| | - Johanna Weiss
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical Faculty Heidelberg, Heidelberg University Hospital, Heidelberg University, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (W.E.H.); (J.W.)
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Xu J, Zhou Q, Hou P, Wang Y, Geng P, Lu Z, Zhou Y, Dai D, Wang S. Effects of bergapten on the pharmacokinetics of macitentan in rats both in vitro and in vivo. Front Pharmacol 2023; 14:1204649. [PMID: 37492094 PMCID: PMC10363979 DOI: 10.3389/fphar.2023.1204649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/27/2023] [Indexed: 07/27/2023] Open
Abstract
Macitentan was approved by the United States Food and Drug Administration (FDA) in 2013 for the treatment of pulmonary arterial hypertension (PAH). Bergapten is a furanocoumarin that is abundant in Umbelliferae and Rutaceae plants and is widely used in many Chinese medicine prescriptions. Considering the possible combination of these two compounds, this study is aimed to investigate the effects of bergapten on the pharmacokinetics of macitentan both in vitro and in vivo. Rat liver microsomes (RLMs), human liver microsomes (HLMs), and recombinant human CYP3A4 (rCYP3A4) were used to investigate the inhibitory effects and mechanisms of bergapten on macitentan in vitro. In addition, pharmacokinetic parameters were also studied in vivo. Rats were randomly divided into two groups (six rats per group), with or without bergapten (10 mg/kg), and pretreated for 7 days. An oral dose of 20 mg/kg macitentan was administered to each group 30 min after bergapten or 0.5% CMC-Na administration on day 7. Blood was collected from the tail veins, and the plasma concentrations of macitentan and its metabolites were assessed by ultra-performance liquid chromatography - tandem mass spectrometer (UPLC-MS/MS). Finally, we analyzed the binding force of the enzyme and two small ligands by in silico molecular docking to verify the inhibitory effects of bergapten on macitentan. The in vitro results revealed that the IC50 values for RLMs, HLMs, and rCYP3A4 were 3.84, 17.82 and 12.81 μM, respectively. In vivo pharmacokinetic experiments showed that the AUC(0-t), AUC(0-∞), and Cmax of macitentan in the experimental group (20,263.67 μg/L*h, 20,378.31 μg/L*h and 2,999.69 μg/L, respectively) increased significantly compared with the control group (7,873.97 μg/L*h, 7,897.83 μg/L*h and 1,339.44 μg/L, respectively), while the CLz/F (1.07 L/h/kg) of macitentan and the metabolite-parent ratio (MR) displayed a significant decrease. Bergapten competitively inhibited macitentan metabolism in vitro and altered its pharmacokinetic characteristics in vivo. Further molecular docking analysis was also consistent with the experimental results. This study provides a reference for the combined use of bergapten and macitentan in clinical practice.
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Affiliation(s)
- Jia Xu
- Department of Pharmacy, The Sencond Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Quan Zhou
- The Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui People’s Hospital, Lishui, Zhejiang, China
| | - Pengjiao Hou
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China
| | - Yu Wang
- The Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui People’s Hospital, Lishui, Zhejiang, China
| | - Peiwu Geng
- The Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui People’s Hospital, Lishui, Zhejiang, China
| | - Zebei Lu
- The Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui People’s Hospital, Lishui, Zhejiang, China
| | - Yunfang Zhou
- The Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui People’s Hospital, Lishui, Zhejiang, China
| | - Dapeng Dai
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China
| | - Shuanghu Wang
- The Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, Lishui People’s Hospital, Lishui, Zhejiang, China
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Nobakht SZ, Akaberi M, Mohammadpour AH, Tafazoli Moghadam A, Emami SA. Hypericum perforatum: Traditional uses, clinical trials, and drug interactions. IRANIAN JOURNAL OF BASIC MEDICAL SCIENCES 2022; 25:1045-1058. [PMID: 36246064 PMCID: PMC9526892 DOI: 10.22038/ijbms.2022.65112.14338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/04/2022] [Indexed: 11/07/2022]
Abstract
Hypericum perforatum (Hypericaceae), known as Saint John’s wort (SJW), has been used in different systems of traditional medicine such as Chinese traditional medicine, Greek traditional medicine, and Islamic traditional medicine. The plant and its active constituents such as hyperforin and hypericin have a wide range of medicinal uses, particularly as anti-depressant, wound-healing, and antibacterial agents. In recent decades, many clinical trials have been performed to investigate the safety and efficacy of this medicinal plant. However, to the best on our knowledge, there is no comprehensive review article in this regard. In the current study, we aim to have a comprehensive review of the clinical trials of SJW to evaluate its efficacy and safety as well as its application in traditional medicine. Clinical studies investigating the safety, interactions, and efficacy of SJW were identified and summarized, including contributions from 2000 until December 2021. According to the results, these clinical studies were divided into three main categories based on the type of disease: psychiatric, endocrine, and skin problems. Important details of the studies, including the type and duration of the study, the type and percentage of the effective compounds or the extract used, the number of patients, and the obtained results were also discussed. In addition, co-administration and drug interaction of SJW with other drugs were summarized. SJW is a valuable medicinal plant, especially for psychiatric disorders. However, precautions should be taken while administrating the plant.
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Affiliation(s)
- Seyedeh Zahra Nobakht
- Department of Traditional Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Akaberi
- Department of Pharmacognosy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Hooshang Mohammadpour
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Tafazoli Moghadam
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Ahmad Emami
- Department of Traditional Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran,Corresponding author: Seyed Ahmad Emami. Department of Traditional Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran. Tel: +98-51-3180 1267; Fax: +98-05118823251;
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Hussein AA, Alvarez P, Reed G, Heresi GA. Off-Label Use and Inappropriate Dosing of Direct Oral Anticoagulants in Cardiopulmonary Disease. Chest 2022; 161:1360-1369. [PMID: 35101404 DOI: 10.1016/j.chest.2022.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 12/28/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are increasingly used in clinical practice and have become essential in the management of atrial fibrillation and VTE. The enthusiasm for DOACs has fueled the off-label application of these agents in cardiopulmonary disease, and their use has often outpaced the evidence supporting their application. This article reviews the evidence and current off-label use of DOACs in various cardiopulmonary disease states.
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Affiliation(s)
- Ayman A Hussein
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland, OH.
| | - Paulino Alvarez
- Section of Heart Failure, Department of Cardiovascular Medicine, Cleveland, OH
| | - Grant Reed
- Section of Interventional Cardiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH
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Scherf-Clavel O. Drug-Drug Interactions With Over-The-Counter Medicines: Mind the Unprescribed. Ther Drug Monit 2022; 44:253-274. [PMID: 34469416 DOI: 10.1097/ftd.0000000000000924] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND This review provides a summary of the currently available clinical data on drug-drug interactions (DDIs) involving over-the-counter (OTC) medicines. It aims to educate and increase awareness among health care providers and to support decisions in daily practice. METHODS An extensive literature search was performed using bibliographic databases available through PubMed.gov. An initial structured search was performed using the keywords "drug-drug-interaction AND (over-the-counter OR OTC)," without further restrictions except for the language. The initial results were screened for all described DDIs involving OTC drugs, and further information was gathered specifically on these drugs using dedicated database searches and references found in the bibliography from the initial hits. RESULTS From more than 1200 initial hits (1972-June 2021), 408 relevant publications were screened for DDIs involving OTC drugs, leading to 2 major findings: first, certain types of drug regimens are more prone to DDIs or have more serious DDI-related consequences, such as antiretroviral, anti-infective, and oral anticancer therapies. Second, although most DDIs involve OTC drugs as the perpetrators, some prescription drugs (statins or phosphodiesterase-5 inhibitors) that currently have OTC status can be identified as the victims in DDIs. The following groups were identified to be frequently involved in DDIs: nonsteroidal anti-inflammatory drugs, food supplements, antacids, proton-pump inhibitors, H2 antihistamines, laxatives, antidiarrheal drugs, and herbal drugs. CONCLUSIONS The most significant finding was the lack of high-quality evidence for commonly acknowledged interactions. High-quality interaction studies involving different phenotypes in drug metabolism (cytochrome P450) and distribution (transporters) are urgently needed. This should include modern and critical drugs, such as oral anticancer medications and direct oral anticoagulants.
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Affiliation(s)
- Oliver Scherf-Clavel
- Institute for Pharmacy and Food Chemistry, University of Würzburg, Würzburg, Germany
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Sensitive UHPLC-MS/MS quantification method for 4β- and 4α-hydroxycholesterol in human plasma for accurate CYP3A phenotyping. J Lipid Res 2022; 63:100184. [PMID: 35181316 PMCID: PMC8953653 DOI: 10.1016/j.jlr.2022.100184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 01/13/2022] [Accepted: 01/19/2022] [Indexed: 11/24/2022] Open
Abstract
4β-Hydroxycholesterol (4β-OHC) is formed by CYP3A4 and CYP3A5 and has drawn attention as an endogenous phenotyping probe for CYP3A activity. However, 4β-OHC is also increased by cholesterol autooxidation occurring in vitro due to dysregulated storage and in vivo by oxidative stress or inflammation, independent of CYP3A activity. 4α-hydroxycholesterol (4α-OHC), a stereoisomer of 4β-OHC, is also formed via autooxidation of cholesterol, not by CYP3A, and thus may have clinical potential in reflecting the state of cholesterol autooxidation. In this study, we establish a sensitive method for simultaneous quantification of 4β-OHC and 4α-OHC in human plasma using ultra-high performance liquid chromatography coupled to tandem mass spectrometry (UHPLC-MS/MS). Plasma samples were prepared by saponification, two-step liquid-liquid extraction, and derivatization using picolinic acid. Intense [M+H]+ signals for 4β-OHC and 4α-OHC di-picolinyl esters were monitored using electrospray ionization. The assay fulfilled the requirements of the US Food and Drug Administration guidance for bioanalytical method validation, with a lower limit of quantification of 0.5 ng/mL for both 4β-OHC and 4α-OHC. Apparent recovery rates from human plasma ranged from 88.2% to 101.5% for 4β-OHC, and 91.8% to 114.9% for 4α-OHC. Additionally, matrix effects varied between 86.2% and 117.6% for 4β-OHC, and between 89.5% and 116.9% for 4α-OHC. Plasma 4β-OHC and 4α-OHC concentrations in healthy volunteers, stage 3-5 chronic kidney disease (CKD) patients, and stage 5D CKD patients as measured by the validated assay were within the calibration ranges in all samples. We propose this novel quantification method may contribute to accurate evaluation of in vivo CYP3A activity.
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Leite PM, Martins MAP, Carvalho MDG, Castilho RO. Mechanisms and interactions in concomitant use of herbs and warfarin therapy: An updated review. Biomed Pharmacother 2021; 143:112103. [PMID: 34474338 DOI: 10.1016/j.biopha.2021.112103] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 12/19/2022] Open
Abstract
This review is an updated and expanded version published in this journal in 2016. Warfarin pharmacotherapy is extremely complex, since in addition to being a low therapeutic index drug, it does not follow the dose-response pattern and has characteristics that predispose the occurrence of interactions, such as high binding rate to plasma proteins, metabolization by cytochrome P450 enzymes, further to acting in the complex process of blood coagulation, platelet activation, and inflammation. For these reasons, warfarin has great potential for interaction with drugs, foods, and herbal medicines. Herb-warfarin interactions, however, are still not very well studied; thus, the objective of this update is to present new information on the subject aiming to provide a scientific basis to help health professionals in the clinical management of these interactions. A literature review was performed from May to June 2021 in multiple databases and articles published in 2016 to 2021 were included. A total of 59 articles describing 114 herbal medicines were reported to interact with warfarin. Of the plants mentioned, 84% had the potential to increase warfarin effect and the risk of bleeding. Targets possibly involved in these interactions include the processes of blood coagulation, platelet activation, and inflammation, in addition to the pharmacokinetics and pharmacodynamics of warfarin. Despite these alarming numbers, however, the clinical management of interactions is known to be effective. Thus, it is important that the use of these herbal medicines be done with caution in anticoagulated patients and that studies of herb-drug interactions be encouraged in order to generate information to support the clinical management of patients.
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Affiliation(s)
- Paula Mendonça Leite
- Department of Pharmaceutical Products, Faculty of Pharmacy, Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, Minas Gerais, Brazil.
| | - Maria Auxiliadora Parreiras Martins
- Department of Pharmaceutical Products, Faculty of Pharmacy, Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, Minas Gerais, Brazil
| | - Maria das Graças Carvalho
- Department of Pharmaceutical Products, Faculty of Pharmacy, Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, Minas Gerais, Brazil
| | - Rachel Oliveira Castilho
- Department of Pharmaceutical Products, Faculty of Pharmacy, Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, Minas Gerais, Brazil; Consórcio Acadêmico Brasileiro de Saúde Integrativa, CABSIN, Brazil.
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Sedhom R, Megaly M, Gupta E, Amanullah A. Use of direct oral anticoagulants in chronic thromboembolic pulmonary hypertension: a systematic review. J Thromb Thrombolysis 2021; 53:51-57. [PMID: 34132973 DOI: 10.1007/s11239-021-02501-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
Direct oral anticoagulants (DOACs) are being increasingly used in patients with chronic thromboembolic hypertension (CTEPH), however, the data on their safety and efficacy are scarce and contradictory. We systematically searched MEDLINE and Google Scholar databases from January 2010 to January 2021 for studies of DOACs in CTEPH. Three observational studies, 2 abstracts and one case series met our inclusion criteria. While these studies reported similar or even less rates of major bleeding in patients receiving DOACs compared with vitamin K antagonists, there were concerns about the possibility of increased risk of venous thromboembolism recurrence with DOAC therapy. Further studies are warranted to better define the role of DOACs in CTEPH.
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Affiliation(s)
- Ramy Sedhom
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA. .,Department of Internal Medicine, Albert Einstein Medical Center, 5501 Old York Rd, Philadelphia, PA, 19141, USA.
| | - Michael Megaly
- Division of Cardiology, Banner University Medical Center, UA College of Medicine, Phoenix, AZ, USA
| | - Ena Gupta
- Department of Pulmonology and Critical Care, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Aman Amanullah
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA.,Division of Cardiology, Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
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Investigating Intestinal Transporter Involvement in Rivaroxaban Disposition through Examination of Changes in Absorption. Pharm Res 2021; 38:795-801. [PMID: 33847849 DOI: 10.1007/s11095-021-03039-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/30/2021] [Indexed: 01/16/2023]
Abstract
PURPOSE The involvement of the intestinally expressed xenobiotic transporters P-glycoprotein (P-gp) and Breast Cancer Resistance Protein (BCRP) have been implicated in rivaroxaban disposition based on in vitro studies, similar to what had previously been proposed for apixaban. We recently showed that these efflux transporters were not clinically relevant for apixaban disposition and examine here their relevance for this second Factor Xa inhibitor. METHODS Using recently published methodologies to discern metabolic- from transporter- mediated drug interactions, a critical evaluation was undertaken of 9 rivaroxaban studies reporting 12 DDIs, one study of food effects and one study of hepatic function. RESULTS Rationale examination of these clinical studies using basic pharmacokinetic theory finds little support for the clinical significance of intestinal efflux transporters in rivaroxaban disposition. Drug-drug interactions are most likely adequately predicted based on the level of CYP 3A metabolism. CONCLUSION These analyses indicate that inhibition of efflux transporters appears to have negligible, clinically insignificant effects on the rivaroxaban absorption process, which is consistent with the concern that predictions based on in vitro measures may not translate to a clinically relevant interaction in vivo. We emphasize the need to evaluate gastric emptying, dissolution and other processes related to absorption when using MAT changes to indicate efflux transporter inhibition.
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Stöllberger C, Finsterer J. Update on drug interactions with non-vitamin-K-antagonist oral anticoagulants for stroke prevention in elderly patients. Expert Rev Clin Pharmacol 2021; 14:569-581. [PMID: 33757376 DOI: 10.1080/17512433.2021.1908124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: We update the knowledge, since the last review in 2017, about drug-drug interactions (DDI) of non-vitamin-K-antagonist oral anticoagulants (NOAC) in patients ≥75 years.Areas covered: The literature was searched for: 'dabigatran,' 'rivaroxaban,' 'edoxaban,' or 'apixaban' and drugs, affecting platelet function, CYP3A4-, CYP2C9-, or P-Gp-activity. Pharmacodynamic DDI of NOAC with drugs affecting platelet function like nonsteroidal anti-inflammatory drugs and antiplatelet agents occur most frequently. Pharmacokinetic DDI with NOAC were found for 37 of 117 drugs. Reports about DDI with NOAC were found for 51% of P-gp-affecting, 38% for CYP2C9-affecting and 27% for CYP3A4-affecting drugs. Reports about DDI of cardiovascular drugs with NOAC were the most prevalent, followed by anti-infective and nervous system drugs. NOAC plasma levels were measured in retrospective and cohort studies and were associated with concomitant medication. Reports about DDI of NOAC were found in 71 patients ≥75 years.Expert opinion: The knowledge about DDI of NOAC in elderly patients is very limited. Studies should be carried out to investigate the role of drugs potentially interacting with NOAC, which until now have not been investigated. When studying DDI of NOAC, care should be taken to include elderly patients with impaired renal function and patients on polymedication.
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Affiliation(s)
- Claudia Stöllberger
- 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse, Wien, Austria
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Scholz I, Liakoni E, Hammann F, Grafinger KE, Duthaler U, Nagler M, Krähenbühl S, Haschke M. Effects of Hypericum perforatum (St John's wort) on the pharmacokinetics and pharmacodynamics of rivaroxaban in humans. Br J Clin Pharmacol 2020; 87:1466-1474. [PMID: 32959922 DOI: 10.1111/bcp.14553] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 08/28/2020] [Accepted: 09/09/2020] [Indexed: 12/30/2022] Open
Abstract
AIMS To investigate the influence of a cytochrome P450 CYP3A4 and efflux transporter P-glycoprotein (P-gp) inducing Hypericum perforatum extract on the pharmacokinetics and pharmacodynamics of rivaroxaban. METHODS Open-label, nonrandomized, sequential treatment interaction study. Following CYP3A4 and P-gp phenotyping using low-dose midazolam and fexofenadine, 12 healthy volunteers received a single oral dose of 20 mg rivaroxaban and rivaroxaban plasma concentrations and inhibition of the activated coagulation factor X (factor Xa) activity were measured prior to and up to 48 h postdosing. The procedures were repeated after 2 weeks' treatment with the H. perforatum extract. RESULTS The geometric mean ratios for the area under the concentration-time curve and Cmax of rivaroxaban after/before induction with the H. perforatum extract were 0.76 (90% confidence interval [CI] 0.70, 0.82) and 0.86 (90% CI 0.76, 0.97), respectively. Inhibition of factor Xa activity was reduced with a geometric mean area under the effect-time curve ratio after/before induction of 0.80 (90% CI 0.71, 0.89). No clinically significant differences were found regarding Tmax (median 1.5 vs 1 h, P = .26) and terminal elimination half-life (mean 10.6 vs 10.8 h, P = .93) of rivaroxaban. The H. perforatum extract significantly induced CYP3A4 and P-gp activity, as evidenced by phenotyping. CONCLUSION The CYP3A4/P-gp inducing H. perforatum extract caused a decrease of rivaroxaban exposure with a proportional decrease of the pharmacodynamic effect. Although the data do not justify a contraindication for the combination or a systematic adjustment of rivaroxaban dosage, avoidance of the combination or laboratory monitoring should be considered in patients taking hyperforin-containing H. perforatum extracts with rivaroxaban.
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Affiliation(s)
- Irene Scholz
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
| | - Evangelia Liakoni
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
| | - Felix Hammann
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
| | - Katharina Elisabeth Grafinger
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
| | - Urs Duthaler
- Division of Clinical Pharmacology & Toxicology, University Hospital Basel, Switzerland.,Department of Biomedicine, University of Basel, Switzerland
| | - Michael Nagler
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, Switzerland
| | - Stephan Krähenbühl
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Division of Clinical Pharmacology & Toxicology, University Hospital Basel, Switzerland.,Department of Biomedicine, University of Basel, Switzerland
| | - Manuel Haschke
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
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Mikus G, Foerster KI, Schaumaeker M, Lehmann M, Burhenne J, Haefeli WE. Application of a microdosed cocktail of 3 oral factor Xa inhibitors to study drug-drug interactions with different perpetrator drugs. Br J Clin Pharmacol 2020; 86:1632-1641. [PMID: 32159869 PMCID: PMC7373712 DOI: 10.1111/bcp.14277] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/20/2020] [Accepted: 03/03/2020] [Indexed: 12/13/2022] Open
Abstract
AIMS Using 3 different perpetrators the impact of voriconazole, cobicistat and rifampicin (single dose), we evaluated the suitability of a microdose cocktail of factor Xa inhibitors (FXaI; rivaroxaban, apixaban and edoxaban; 100 μg in total) to study drug-drug interactions. METHODS Three cohorts of 6 healthy volunteers received 2 treatments with microdoses of rivaroxaban, apixaban and edoxaban alone and with coadministration of 1 of the perpetrators. Plasma and urine concentrations of microdosed apixaban, edoxaban and rivaroxaban were quantified using a validated ultra-performance liquid chromatography-tandem mass spectrometry with a lower limit of quantification of 2.5 pg/mL. RESULTS Voriconazole caused only a minor interaction with apixaban and rivaroxaban, none with edoxaban. Cobicistat significantly increased exposure of all 3 FXaI with area under the plasma concentration-time curve ratios of 1.67 (apixaban), 1.74 (edoxaban) and 2.0 (rivaroxaban). A single dose of rifampicin decreased the volume of distribution and elimination half-life of all 3 FXaI. CONCLUSIONS The microdosed FXaI cocktail approach is able to generate drug interaction data and can help elucidating the mechanism involved in the clearance of the different victim drugs. This is a safe approach to concurrently study drug-drug interactions with a drug class. (EudraCT 2016-003024-23).
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Affiliation(s)
- Gerd Mikus
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Kathrin I. Foerster
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Marlene Schaumaeker
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Marie‐Louise Lehmann
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
| | - Walter E. Haefeli
- Department of Clinical Pharmacology and PharmacoepidemiologyUniversity Hospital HeidelbergIm Neuenheimer Feld 41069120HeidelbergGermany
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Foerster KI, Hermann S, Mikus G, Haefeli WE. Drug-Drug Interactions with Direct Oral Anticoagulants. Clin Pharmacokinet 2020; 59:967-980. [PMID: 32157630 PMCID: PMC7403169 DOI: 10.1007/s40262-020-00879-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A large body of evidence suggests that not only direct anticoagulant effects but also major bleeding events and stroke prevention depend on plasma concentrations of direct oral anticoagulants (DOACs). Concomitant drugs that cause drug–drug interactions (DDIs) alter DOAC exposure by increasing or decreasing DOAC bioavailability and/or clearance; hence, they might affect the efficacy and safety of DOAC therapy. Patients with renal impairment already receive smaller DOAC maintenance doses because avoidance of elevated DOAC exposure might prevent serious bleeding events. For other causes of increased exposure such as DDIs, management is often less well-defined. Considering that DOAC patients are often older and have multiple co-morbidities, polypharmacy is highly prevalent. However, the effect of multiple drugs on DOAC exposure, and especially the impact of DDIs when concurring with drug–disease interactions as observed in renal impairment, has not been thoroughly elucidated. In order to provide effective and safe anticoagulation with DOACs, understanding the mechanisms and magnitude of DDIs appears relevant. Instead of avoiding drug combinations with DOACs, more DDI trials should be conducted and new strategies such as dose adjustments based on therapeutic drug monitoring should be investigated. However, dose adjustments based on concentration measurements cannot currently be recommended because evidence-based data are missing.
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Affiliation(s)
- Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Simon Hermann
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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Indications and potential pitfalls of anticoagulants in pulmonary hypertension: Would DOACs become a better option than VKAs? Blood Rev 2019; 37:100579. [DOI: 10.1016/j.blre.2019.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/29/2019] [Accepted: 05/14/2019] [Indexed: 01/23/2023]
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Brings A, Lehmann ML, Foerster KI, Burhenne J, Weiss J, Haefeli WE, Czock D. Perpetrator effects of ciclosporin (P-glycoprotein inhibitor) and its combination with fluconazole (CYP3A inhibitor) on the pharmacokinetics of rivaroxaban in healthy volunteers. Br J Clin Pharmacol 2019; 85:1528-1537. [PMID: 30912163 DOI: 10.1111/bcp.13934] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 03/01/2019] [Accepted: 03/20/2019] [Indexed: 12/25/2022] Open
Abstract
AIMS Rivaroxaban exposure is considerably increased by drugs that are combined P-glycoprotein (P-gp) and strong cytochrome P450 (CYP) 3A inhibitors (e.g. ketoconazole). The aim of the present study was to investigate the effects of the potent P-gp inhibitor ciclosporin and its combination with the moderate CYP3A inhibitor fluconazole on rivaroxaban pharmacokinetics and on CYP3A activity. METHODS Twelve healthy volunteers received 20 mg rivaroxaban orally alone, in combination with ciclosporin (dose-individualized oral regimen), and in combination with ciclosporin and fluconazole (400 mg day-1 orally). CYP3A4 activity was estimated using a midazolam microdose. Pharmacokinetics was analysed using noncompartmental and compartmental methods. RESULTS Compared to baseline, ciclosporin increased rivaroxaban average exposure by 47% (90% confidence interval 28-68%), maximum concentration by 104% (70-146%), and decreased CYP3A4 activity by 34% (25-42%). Ciclosporin combined with fluconazole increased rivaroxaban average exposure by 86% (58-119%) and maximum concentration by 115% (83-153%), which was considerably stronger than observed in historical controls receiving rivaroxaban with fluconazole alone, and decreased CYP3A4 activity by 79% (76-82%). CONCLUSION Patients treated with rivaroxaban in combination with single modulators of multiple elimination pathways or multiple modulators of single elimination pathways (CYP3A, P-gp) require particular care.
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Affiliation(s)
- Antonia Brings
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Marie-Louise Lehmann
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Johanna Weiss
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - David Czock
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
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Huppertz A, Werntz L, Meid AD, Foerster KI, Burhenne J, Czock D, Mikus G, Haefeli WE. Rivaroxaban and macitentan can be coadministered without dose adjustment but the combination of rivaroxaban and St John's wort should be avoided. Br J Clin Pharmacol 2018; 84:2903-2913. [PMID: 30192025 DOI: 10.1111/bcp.13757] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/28/2018] [Accepted: 09/03/2018] [Indexed: 12/15/2022] Open
Abstract
AIMS We assessed the potential mutual interaction of oral macitentan (cytochrome P450 (CYP) 3A4 substrate) at steady-state with single-dose oral rivaroxaban (CYP3A4 and P-glycoprotein substrate) and evaluated the effect of the CYP3A and P-glycoprotein inducer St John's wort (SJW) on the pharmacokinetics of these drugs in healthy volunteers. METHODS Twelve healthy volunteers completed this open-label, monocentre, two-period, one-sequence phase I clinical trial. The pharmacokinetics of macitentan (10 mg) was assessed on study days 3 (single dose), 15 (steady-state), 16 (impact of rivaroxaban) and 29 (after induction by oral SJW), and of rivaroxaban on days 2 (single dose), 16 (impact of macitentan at steady-state) and 29 (after induction by SJW). Concurrently, we quantified changes of CYP3A activity using oral microdoses of midazolam (30 μg). RESULTS Rivaroxaban and macitentan did not significantly change the pharmacokinetics of each other. After induction with SJW, CYP3A activity increased by 272% and geometric mean ratios of macitentan AUC decreased by 48% and of Cmax by 45%. Concurrently, also geometric mean ratios of rivaroxaban AUC and Cmax decreased by 25%. CONCLUSIONS There is no evidence for a relevant pharmacokinetic interaction between macitentan and rivaroxaban suggesting that these two drugs can be combined without dose adjustment. SJW strongly increased CYP3A activity and substantially reduced rivaroxaban and macitentan exposure while estimated net endothelin antagonism only decreased by 20%, which is considered clinically irrelevant. The combination of SJW with rivaroxaban should be avoided.
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Affiliation(s)
- Andrea Huppertz
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Lars Werntz
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - David Czock
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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