The Strength of hERG Inhibition by Erythromycin at Different Temperatures Might Be Due to Its Interacting Features with the Channels.

Erythromycin is one of the few compounds that remarkably increase ether-a-go-go-related gene (hERG) inhibition from room temperature (RT) to physiological temperature (PT). Understanding how erythromycin inhibits the hERG could help us to decide which compounds are needed for further studies. The whole-cell patch clamp technique was used to investigate the effects of erythromycin on hERG channels at different temperatures. While erythromycin caused a concentration-dependent inhibition of cardiac hERG channels, it also shifted the steady-state activation and steady-state inactivation of the channel to the left and significantly accelerated the onset of inactivation at both temperatures, although temperature itself caused a profound change in the dynamics of hERG channels. Our data also suggest that the binding pattern to S6 of the channels changes at PT. In contrast, cisapride, a well-known hERG blocker whose inhibition is not affected by temperature, does not change its critical binding sites after the temperature is raised to PT. Our data suggest that erythromycin is unique and that the shift in hERG inhibition may not apply to other compounds.

Protein binding-dependent decreases in hERG channel blocker potency assessed by whole-cell voltage clamp in serum.

In vitro hERG blocking potency is measured in drug discovery as part of an integrated cardiovascular risk assessment. Typically, the concentrations producing 50% inhibition are measured in protein-free saline solutions and compared with calculated free therapeutic in vivo Cmax values to estimate a hERG safety multiple. The free/unbound fraction is believed responsible for activity. We tested the validity of this approach with 12 compounds by determining potencies in voltage clamp studies conducted in the absence and presence of 100% dialyzed fetal bovine serum (FBS). Bath drug concentrations in saline solutions were measured to account for loss of compounds due to solubility, stability, and/or adsorption. Protein binding in dialyzed FBS was measured to enable predictions of serum IC50s based on the unbound fraction and the saline IC50. For 11 of 12 compounds, the measured potency in the presence of dialyzed FBS was within 2-fold of the predicted potency. The predicted IC50 in dialyzed FBS for one highly bound compound, amiodarone, was 9-fold higher than the measured serum IC50. These data suggest that for highly bound compounds, direct measurement of IC50s in the presence of 100% serum may provide a more accurate estimate of in vivo potencies than the approach based on calculated serum shifts.

Investigating dynamic protocol-dependence of hERG potassium channel inhibition at 37 degrees C: Cisapride versus dofetilide.

INTRODUCTION: Pharmacological inhibition of cardiac potassium channels encoded by hERG (human ether-à-go-go-related gene) is associated with QT interval prolongation and torsades de pointes arrhythmia. Electrophysiological assays of hERG channel inhibition are integral to the safety testing of novel drug candidates. This study was conducted to compare, for the high affinity hERG inhibitors dofetilide and cisapride, hERG blockade between action potential (AP) and conventional (step and step-ramp) screening waveforms. Furthermore, it evaluated dynamic (pulse-by-pulse) protocol-dependence of hERG channel inhibition by these drugs. METHODS: Whole-cell patch-clamp recordings were made at 37 degrees C from hERG-expressing HEK 293 cells. Half-maximal inhibitory concentrations (IC(50) values) for I(hERG) blockade were obtained using conventional voltage clamp and action potential clamp, using previously digitised ventricular and Purkinje fibre (PF) AP waveforms. RESULTS: A more marked variation in IC(50) values with different command waveforms was observed for cisapride (ranging from 7 to 72 nM) than for dofetilide (ranging from 4 to 15 nM), with higher IC(50)s obtained with AP than step or step-ramp commands. The two drugs differed little from one another in effects on voltage-dependent activation; however, I(hERG) blockade by each drug was initially voltage-dependent, but at steady-state was only voltage-dependent for cisapride. There was comparatively little difference between the two drugs in effects on I(hERG) availability or time constants of development of inactivation. Features of time-dependence of blockade and the use of protocols employing varying rest periods in drug or commands of alternating duration highlighted a pronounced ability of cisapride, but not dofetilide, to dissociate and reassociate from hERG on a pulse-by-pulse basis. DISCUSSION: Protocols described here that demonstrated dynamic variation (drug dissociation/reassociation) in hERG channel current blockade at 37 degrees C for cisapride may have future value for investigating drug interactions with the hERG channel. Downloadable digitised ventricular and PF AP waveforms that can be used in AP clamp experiments also accompany this article.

Docking model of drug binding to the human ether-à-go-go potassium channel guided by tandem dimer mutant patch-clamp data: a synergic approach.

To characterize drug binding to the human ether-a-go-go related gene (hERG) channel, a synergic approach interplaying patch-clamp experiments and a docking study was developed. Mutations were introduced into concatenated dimers of the hERG channel that were assembled into a heterotetramer with mutated diagonal subunits. The binding affinities of three drugs (cisapride, terfenadine, and N-[4-[[1-[2-(6-methyl-2-pyridinyl)ethyl]-4-piperidinyl]carbonyl]phenyl]methanesulfonamide dihydrochloride (E-4031, 1)) to a set of mutant channels were examined electrophysiologically to assess the involved residues, their number, and relative positions. Cisapride and 1 interacted with Tyr652 residues on adjacent subunits, while terfenadine interacted with Tyr652 residues on diagonal, but not on adjacent, subunits. Phe656 was involved in the binding of all three drugs, and Ser624 was found to be only involved in cisapride and 1. The docking models demonstrated that pi-pi and CH-pi interactions rather than cation-pi interaction play a key role in drug binding to the hERG channel.

Molecular determinants of hERG channel block by terfenadine and cisapride.

Block of cardiac hERG K+ channels by the antihistamine terfenadine and the prokinetic agent cisapride is associated with prolonged ventricular repolarization and an increased risk of ventricular arrhythmia. Here, we used a site-directed mutagenesis approach to determine the molecular determinants of hERG block by terfenadine and cisapride. Wild-type and mutant hERG channels were heterologously expressed in Xenopus laevis oocytes and characterized by measuring whole cell currents with two-microelectrode voltage clamp techniques. Mutation of T623, S624, Y652, or F656 to Ala reduced channel sensitivity to block by terfenadine. The same mutations reduced sensitivity to cisapride. These data confirm our previous findings that polar residues (T623, S624) located near the base of the pore helix and aromatic residues (Y652, F656) located in the S6 domain are key molecular determinants of the hERG drug binding site. Unlike methanesulfonanilides (dofetilide, MK-499, E-4031, ibutilide) or clofilium, mutation of V625, G648, or V659 did not alter the sensitivity of hERG channels to terfenadine or cisapride. As previously proposed by molecular modeling studies (Farid R, et al. Bioorg Med Chem. 2006;14:3160-3173), our findings suggest that different drugs can adopt distinct modes of binding to the central cavity of hERG.

Topological mapping of the asymmetric drug binding to the human ether-à-go-go-related gene product (HERG) potassium channel by use of tandem dimers.

The human ether-à-go-go related gene product (HERG) channel is essential for electrical activity of heart cells, and block of this channel by many drugs leads to lethal arrhythmias. Tyr(652) and Phe(656) of the sixth transmembrane helix are candidates for the drug binding site. In the tetrameric HERG channel, a drug with asymmetric structure should interact unevenly with multiple residues from different subunits. To elucidate the topology of the drug-binding site, we constructed tandem dimers of HERG channels and the aromatic Tyr(652) and Phe(656) residues were replaced by alanine singly or doubly. Eight types of HERG channels, including homotetrameric mutants, having different numbers and arrangements of aromatic residues at the blocking site, were studied. Effects of cisapride on channels expressed in Xenopus laevis oocytes were examined electrophysiologically. The inhibition constants (K(i)) were increased significantly as the diagonal Tyr(652) were deleted, whereas those for the diagonal Phe(656)-deleted mutant were not changed. These results suggest that Tyr(652) residues from adjacent subunits contributed to the binding. Two types of double mutants of tandem dimers showed significantly distinct affinities, suggesting that the coexistence of Tyr(652) and Phe(656) on a subunit in diagonal position is crucial to having a high affinity. Thermodynamic double-mutant cycle analyses revealed interactions between Tyr(652) and Phe(656) upon binding. The kinetics and voltage-dependence of blocking suggested transitions of the binding site from low to high affinity. These approaches using a set of mutant HERG channels gave a dynamic picture of the spatial arrangements of residues that contribute to the drug-channel interaction.

The effects of plasma proteins on delayed repolarization in vitro with cisapride, risperidone, and D, L-sotalol.

INTRODUCTION: Drug-induced long QT syndrome (LQTS) has been linked to arrhythmias (including Torsades de Pointes and sudden cardiac death), and has led to an increased awareness of the potential risk of delayed repolarization in vitro and in vivo. However, in vitro assessments of delayed repolarization have not been fully predictive of in vivo effects. METHODS: To define the extent to which plasma protein binding (ppb) contributes to such disparities in repolarization studies, we compared drug-induced prolongation of the canine Purkinje fiber action potential duration (APD(90)) in vitro during superfusion with 100% Tyrode's solution (Tyrodes), canine plasma [50% plasma/50% Tyrodes] and a 5% solution of recombinant human serum albumin in Tyrodes (HSA). Drugs evaluated included cisapride (>98% ppb), risperidone (90% ppb), and d, l-sotalol (negligible ppb). Effects on APD were monitored using standard microelectrode techniques under physiologic conditions and temperature ([K(+)]=4 mM, 37 degrees C) during slow stimulation (2 s basic cycle length). RESULTS: The effects of cisapride and risperidone on Purkinje fiber APD(90) were significantly attenuated in the presence of plasma proteins. However, with cisapride, the extent of reduction with plasma proteins was significantly less than predicted based on calculated free drug levels. DISCUSSION: We conclude that while plasma protein binding does reduce APD prolongation seen with bound drugs, this effect is not well correlated with the calculated plasma protein binding or expected clinical free fraction. Because of the complex drug interactions that occur in plasma, the electrophysiological effects seen with bound drugs are not well correlated with the calculated free fraction and thus caution should be exercised when assigning a predictive safety window. Thus, the canine Purkinje fiber assay is useful for defining the modulation of delayed repolarization due to plasma protein binding of novel therapeutic agents.

Molecular determinants of cocaine block of human ether-á-go-go-related gene potassium channels.

The use of cocaine causes cardiac arrhythmias and sudden death. Blockade of the cardiac potassium channel human ether-á-go-go-related gene (hERG) has been implicated as a mechanism for the proarrhythmic action of cocaine. hERG encodes the pore-forming subunits of the rapidly activating delayed rectifier K(+) channel (I(Kr)), which is important for cardiac repolarization. Blockade of I(Kr)/hERG represents a common mechanism for drug-induced long QT syndrome. The mechanisms for many common drugs to block the hERG channel are not well understood. We investigated the molecular determinants of hERG channels in cocaine-hERG interactions using site-targeted mutations and patch-clamp method. Wild-type and mutant hERG channels were heterologously expressed in human embryonic kidney 293 cells. We found that there was no correlation between inactivation gating and cocaine block of hERG channels. We also found that consistent with Thr-623, Tyr-652, and Phe-656 being critical for drug binding to hERG channels, mutations in these residues significantly reduced cocaine-induced block, and the hydrophobicity of the residues at position 656 dictated the cocaine sensitivity of the channel. Although the S620T mutation, which removed hERG inactivation, reduced cocaine block by 21-fold, the S620C mutation, which also completely removed hERG inactivation, did not affect the blocking potency of cocaine. Thus, Ser-620 is another pore helix residue whose mutation can interfere with cocaine binding independently of its effect on inactivation.

Modulatory role of verapamil treatment on the cardiac electrophysiological effects of cisapride.

The role of transport proteins in the distribution of drugs in various tissues has obvious implications for drug effects. Recent reports indicate that such transporters are present not only in the liver, intestine, or blood-brain barrier but also in the heart. The objective of our study was to determine whether treatment of animals with verapamil, a well-known L-type calcium channel blocker with modulatory properties of membrane transporters, would alter distribution and cardiac electrophysiological effects of an I(Kr) blocker. Male guinea pigs (n = 72) were treated with either saline or verapamil at various doses (1.5 to 15 mg/kg) and for various durations (1 to 7 d). Animals were sacrificed 24 h after the last dose of verapamil (or saline), and their hearts were isolated and retroperfused with cisapride, a gastrokinetic drug with I(Kr) blockade properties. In hearts obtained from animals treated with vehicle, 50 nmol/L cisapride prolonged MAPD90 by 15 +/- 5 ms vs. 36 +/- 8 ms in hearts from animals treated with verapamil 15 mg.kg(-1).d(-1) for 5 d (p < 0.01). Treatment effects were dose- and time-dependent. Cardiac myocytes isolated from animals treated with vehicle or verapamil were incubated for 3 h with 100 ng/mL cisapride. Intracellular concentrations of cisapride in cardiac myocytes from animals treated with verapamil were 1.6-fold higher than those measured in myocytes from animals treated with vehicle (p < 0.01). The increase in intracellular concentrations of cisapride and potentiation of cisapride electrophysiological effects suggest that chronic treatment with drugs such as verapamil may modulate drug effects on the QT interval because of an increased access to intracellular binding sites on I(Kr) channels.

Intracellular K+ is required for the inactivation-induced high-affinity binding of cisapride to HERG channels.

Many commonly used medications can cause long QT syndrome and thus increase the risk of life-threatening arrhythmias. High-affinity human Ether-à-go-go-related gene (HERG) potassium channel blockade by structurally diverse compounds is almost exclusively responsible for this side effect. Understanding drug-HERG channel interactions is an important step in avoiding drug-induced long QT syndromes. Previous studies have found that disrupting HERG inactivation reduces the degree of drug block and have suggested that the inactivated state is the preferential state for drug binding to HERG channels. However, recent studies have also shown that inactivation does not dictate drug sensitivity of HERG channels. In the present study, we examined the effect of inactivation gating on cisapride block of HERG. Modulation of HERG inactivation was achieved by either changing extracellular K+ or Cs+ concentrations or by mutations of the channel. We found that although inactivation facilitated cisapride block of the HERG K+ current, it was not coupled with cisapride block of HERG when the Cs+ current was recorded. Furthermore, cisapride block of the HERG K+ current was not linked with inactivation in the mutant HERG channels F656V and F656M. Our results suggest that inactivation facilitates cisapride block of HERG channels through affecting the positioning of Phe-656.

Drug-drug interactions of Z-338, a novel gastroprokinetic agent, with terfenadine, comparison with cisapride, and involvement of UGT1A9 and 1A8 in the human metabolism of Z-338.

In the present study, the inhibitory properties of N-[2-(diisopropylamino)ethyl]-2-[(2-hydroxy-4,5-dimethoxybenzoyl)amino]-1,3-thiazole-4-carboxamide monohydrochloride trihydrate (Z-338), a novel gastroprokinetic agent, were investigated and compared with those of cisapride to establish its potential for drug-drug interactions. There was no notable inhibition of terfenadine metabolism or of any of the isoforms of cytochrome P450 (CYP1A1/2, 2A6, 2B6, 2C9, 2C19, 2D6, 2E1 and 3A4) by Z-338 in in vitro studies using human liver microsomes. Z-338 was mainly metabolized to its glucuronide by UGT1A9 (UDP glucoronosyltransferase 1 family, polypeptide A9) and UGT1A8, and did not show marked inhibition of P-glycoprotein activity. On the other hand, cisapride strongly inhibited CYP3A4 and markedly inhibited CYP2C9. Furthermore, we used the whole-cell patch-clamp technique to investigate the effects of Z-338 and cisapride on potassium currents in human embryonic kidney (HEK) 293 cells transfected with the human ether-a-go-go-related gene (hERG). Z-338 had no significant effect on hERG-related current at the relatively high concentration of 10 microM. In contrast, the inhibition by Z-338 was very small compared with that of cisapride at 10 nM, which was a thousand-fold lower concentration. In the prediction method for the drug interaction between terfenadine and cisapride based on the K(i) and PK parameters, we suggest the possibility that terfenadine mainly affect the QT interval, since its plasma concentration would be markedly increased, but cisapride may not be changed. Thus, in contrast with cisapride, Z-338 did not inhibit CYP and the hERG channel, and is predominantly metabolized by glucuronide conjugation, Z-338 is considered unlikely to cause significant drug-drug interactions when coadministered with CYP substrates at clinically effective doses.

Cisapride disposition in neonates and infants: in vivo reflection of cytochrome P450 3A4 ontogeny.

BACKGROUND: Cisapride, a prokinetic agent and substrate for cytochrome P450 (CYP) 3A4, has been used to treat neonates and infants with feeding intolerance and apnea or bradycardia associated with gastroesophageal reflux. At age 1 month, CYP3A4 activity has been reported to be only 30% to 40% of adult activity. This known developmental delay in the expression of CYP3A4 prompted us to conduct a classical open-label pharmacokinetic study of cisapride in neonates and young infants. METHODS: A total of 35 infants with a postconceptional age of 28 to 54 weeks at the time of the study received a single oral cisapride dose (0.2 mg/kg) at a postnatal age of 4 to 102 days, followed by repeated (n = 7) blood sampling over a 24-hour period. Cisapride and norcisapride were quantitated from plasma by HPLC-tandem mass spectrometry and pharmacokinetic data determined (n = 32) by noncompartmental methods. RESULTS: The pharmacokinetic parameters (mean +/- SD) were as follows: time to reach peak plasma concentration (t(max)), 4.4 +/- 2.8 hours (range, 0.9-12 hours); peak plasma concentration (C(max)), 29.3 +/- 16.6 ng/mL (range, 5.2-71.7 ng/mL); elimination half-life (t(1/2)), 10.7 +/- 3.7 hours (range, 1.9-18.1 hours); apparent total body clearance (Cl/F), 0.62 +/- 0.43 L. h(-1). kg(-1) (range, 0.2-1.9 L. h(-1). kg(-1)); and apparent volume of distribution (VD(ss)/F), 9.0 +/- 7.1 L/kg (range, 2.2-30.5 L/kg). The apparent renal clearance (CL(R)) of cisapride in infants (n = 28) was estimated to be 0.003 +/- 0.003 L. h(-1). kg(-1). Substratification of the population based on postconceptional age demonstrated the following findings for cisapride: (1) The mean (+/-SD) C(max) for cisapride was higher in the oldest postconceptional age category (44.5 +/- 19.6 ng/mL) than the middle and youngest categories (23.4 +/- 11.7 ng/mL and 30.0 +/- 17.5 ng/mL, respectively); (2) the t(max) for cisapride was shortest in the oldest postconceptional age category (2.2 +/- 1.1 hours) compared with the middle and youngest categories (4.4 +/- 3.3 hours and 5.0 +/- 2.6 hours, respectively); (3) the CL/F for cisapride in the youngest postconceptional age group was significantly lower (0.45 +/- 0.26 L. h(-1). kg(-1), P <.05) than in the middle and oldest categories (0.75 +/- 0.46 L. h(-1). kg(-1) and 0.85 +/- 0.69 L. h(-1). kg(-1), respectively); (4) a positive linear correlation was found between postconceptional age and the apparent terminal elimination rate constant (lambda(z)) for cisapride (P <.001, r(2) = 0.47) but not with CL/F. For norcisapride, the mean apparent C(max) was highest and the t(max) was shortest in the oldest postconceptional age group, although no association between postconceptional age and the norcisapride/cisapride area under the curve ratio was observed. All infants tolerated a single dose of cisapride well without significant alteration in QTc. CONCLUSIONS: (1) In neonates and infants, cisapride absorption and metabolism to its primary metabolite, norcisapride, were developmentally dependent; (2) approximately 99% of cisapride CL/F in neonates and young infants was nonrenal in nature; (3) CL/F of cisapride in neonates and infants noted in this study was reduced compared with data from older children and adults, likely as a result of developmental reductions in CYP3A4 activity; (4) as reflected by the correlation between postconceptional age and lambda(z), a rapid increase in total CYP3A4 activity occurs in the first 3 months of life.

Evidence of impaired cisapride metabolism in neonates.

AIMS: Cisapride has been shown to cause QTc prolongation in neonates in the absence of any of the known risk factors ascribed to children or adults (excessive dosage, drug-drug interactions). Our hypothesis was that the early neonatal liver may show defective elimination of cisapride resulting in its accumulation in the immature child. Owing to the difficulties associated with in vivo pharmacokinetic studies in a paediatric population, we explored the in vitro metabolism of cisapride by human cytochrome P450. METHODS: Experiments were conducted with recombinant CYPs stably expressed in mammalian cells and with liver microsomes obtained from human foetuses, neonates, infants and adults. Cisapride metabolites were measured by high performance liquid chromatography. RESULTS: The rate of biotransformation of cisapride was greater by recombinant CYP3A4 than by CYP3A7 (0.77 +/- 0.5 and 0.01 +/- 0.01 nmol metabolites formed in 24 h, respectively), whereas CYP1A1, 1A2, 2C8, 2C9 and 3A5 showed no activity. Norcisapride formation was significantly correlated with testosterone 6beta-hydroxylation, a CYP3A4 catalysed reaction (r = 0.71, P = 0.03) but not with the 16-hydroxylation of dehydroepiandrosterone, catalysed by CYP3A7 (r = 0.30, P = 0.29) by microsomes from a panel of livers from foetuses, neonates and infants. No or negligible cisapride metabolic activity was observed in microsomes from either foetuses or neonates aged less than 7 days, which contained mostly CYP3A7 and no CYP3A4. The metabolism of cisapride steadily increased after the first week of life in parallel with CYP3A4 activity to reach levels exceeding adult values. CONCLUSIONS: The low content of CYP3A4 in the human neonatal liver appears to be responsible for its inability to oxidize cisapride and could explain its accumulation in plasma leading to the cases of QTc prolongation reported in this paediatric population.

Stereoselective metabolism of cisapride and enantiomer-enantiomer interaction in human cytochrome P450 enzymes: major role of CYP3A.

Cisapride is a chiral molecule that is marketed as a racemate consisting of two optical isomers, but little is known about its stereoselective metabolism. Studies with (-)-, (+)-, and (+/-)-cisapride were undertaken in human liver microsomes (HLMs) and recombinant cytochrome P450s (P450s) to determine the stereoselective metabolism and enantiomer-enantiomer interaction. Each enantiomer and racemic cisapride were N-dealkylated to norcisapride (NORCIS) and hydroxylated to 3-fluoro-4-hydroxycisapride (3-F-4-OHCIS) and 4-fluoro-2-hydroxycisapride (4-F-2-OHCIS). The kinetics for the formation of NORCIS from (-)-cisapride (Km = 11.9 +/- 4.8 microM; Vmax = 203 +/- 167 pmol/min/mg of protein) or (+)-cisapride (Km = 18.5 +/- 4.7 microM; Vmax = 364 +/- 284 pmol/min/mg of protein) in HLMs exhibited simple Michaelis-Menten kinetics, while a sigmoidal model characterized those of 3-F-4-OHCIS and 4-F-2-OHCIS. In vitro, NORCIS appears to be the major metabolite of both enantiomers. NORCIS and 3-F-4-OHCIS were preferentially formed from (+)-cisapride rather than (-)-cisapride, but that of 4-F-2-OHCIS was the reverse, suggesting regio- and stereoselective metabolism. The formation rate of each metabolite from each enantiomer (20 microM) in 18 HLMs was highly variable (e.g., NORCIS, >35-fold) and correlated with the activity of CYP3A (r = 0.6-0.85; p < 0.05). Coincubation of troleandomycin (50 microM) with cisapride enantiomers (15 microM) in HLMs resulted in potent inhibition of NORCIS formation (by 75-80%), while other inhibitors showed negligible effect. Of 10 recombinant human P450s tested, CYP3A4 catalyzed the formation of NORCIS, 3-F-4-OHCIS, and 4-F-2-OHCIS from each enantiomer and racemic cisapride (15 microM) with the highest specific activity (Km values close to those in HLMs). We noted that the rate of racemic cisapride metabolism by HLMs and recombinant human CYP3A4 is slower compared with equimolar concentrations of each enantiomer. When incubated simultaneously in HLMs, the enantiomers inhibit each other's metabolism. In conclusion, our data demonstrate for the first time the stereoselective metabolism and enantiomer-enantiomer interaction of cisapride. Provided that the potency or the response of the enantiomers differ, understanding the factors that control their disposition as opposed to that of racemic cisapride may better predict adverse drug interactions and the resulting prokinetic efficacy and cardiac safety of cisapride.

Frequency and clinical outcome of potentially harmful drug metabolic interactions in patients hospitalized on internal and pulmonary medicine wards: focus on warfarin and cisapride.

Drug metabolic interactions present potential risks in patient care, but their frequency and relative importance as a clinical problem remains unclear. To assess the frequency and clinical outcome of potentially harmful drug metabolic interactions in hospitalized patients, the authors performed a survey of the medication data of patients treated on internal and pulmonary medicine wards in a university hospital. The database was searched for concomitantly administered drug pairs that would, according to Hansten and Horn's drug interaction database, carry a high risk for a clinically harmful metabolic drug interaction. Coadministrations involving warfarin or cisapride were subjected to further analysis regarding clinical outcome. A total of 142 patients were exposed to 150 interactions with potentially harmful clinical outcome, resulting in a frequency of 0.9% (95% CI 0.7% to 1.0%). Inhibition of warfarin metabolism by metronidazole produced significant overanticoagulation as evidenced by elevated international normalized ratio values, whereas inducers (rifampicin and phenobarbital) of warfarin metabolism significantly reduced the efficacy of warfarin. One case of minor bleeding and one case of clavicular vein thrombosis were detected as possible consequences of disturbed anticoagulation. The coadministration of cisapride and erythromycin significantly prolonged the corrected QT (QTc) interval and was associated with clinical symptoms of cardiac arrhythmias. Coadministration of cisapride with fluconazole or miconazole was not associated with prolongation of the QTc interval or cardiac sequelae. Evaluations of patient materials are needed to assess the clinical relevance of metabolic drug interactions.

The involvement of flavin-containing monooxygenase but not CYP3A4 in metabolism of itopride hydrochloride, a gastroprokinetic agent: comparison with cisapride and mosapride citrate.

The goals of the present study were to identify the enzyme responsible for metabolism of itopride hydrochloride (itopride) and to evaluate the likelihood of drug interaction involving itopride. In human liver microsomes, the involvement of flavin-containing monooxygenase in N-oxygenation, the major metabolic pathway of itopride, was indicated by the following results: inhibition by methimazole and thiourea, heat inactivation, and protection against heat inactivation by NADPH. When the effects of ketoconazole on the metabolism of itopride, cisapride, and mosapride citrate (mosapride) were examined using human liver microsomes, ketoconazole strongly inhibited the formation of the primary metabolites of cisapride and mosapride, but not itopride. Other cytochrome P450 (CYP) 3A4 inhibitors, cimetidine, erythromycin, and clarithromycin, also inhibited the metabolism of cisapride and mosapride. In an in vivo study, itopride (30 mg/kg), cisapride (1.5 mg/kg), or mosapride (3 mg/kg) was orally administered to male rats with or without oral pretreatment with ketoconazole (120 mg/kg) twice daily for 2 days. The ketoconazole pretreatment significantly increased the area under the serum concentration curve and the maximum serum concentration of cisapride and mosapride but had no significant effect on the pharmacokinetics of itopride. In addition, itopride did not inhibit five specific CYP-mediated reactions of human liver microsomes. These results suggest that itopride is unlikely to alter the pharmacokinetics of other concomitantly administered drugs.

Relationships between transit time in man and in vitro fermentation of dietary fiber by fecal bacteria.

OBJECTIVE: To assess the effects of drug-induced changes in mean transit time (MTT) on the activity of human fecal flora in vitro. METHODS: The activity of fecal flora was estimated by the ability of a fecal inoculum to ferment a substrate (beet fiber) in vitro in a batch system for 24 h. The inoculum was collected from 8 healthy volunteers studied during three 3-week randomized periods, who received a controlled diet alone (control period) or the same diet with either cisapride or loperamide. Cisapride and loperamide were adjusted in order to halve and double MTT measured during the control period. At the end of each period, the percentage disappearance of the initial added substrate and the concentration and the profile of short-chain fatty acids (SCFAs), were determined. RESULTS: In the control period, the pH of the inoculum and SCFA concentration were inversely related to MTT (P=0.0001). Individual SCFA production was also significantly related to MTT (P<0.01). Cisapride-reduced transit time was associated with a significant rise in the concentrations of total SCFAs (P<0.05), propionic and butyric acids (P<0.05) and the percentage substrate disappearance (P<0.05). Inverse relations were observed during the loperamide period. Moreover, MTT was inversely related to the percentage substrate disappearance (P<0.001), SCFA production (P<0.001) and butyrate production (P<0.0005). CONCLUSION: Changes in MTT alter bacterial activity and modify the bacterial pathways affecting the proportion of individual SCFAs. European Journal of Clinical Nutrition (2000) 54, 603-609

Identification of the cytochrome P450 enzymes involved in the metabolism of cisapride: in vitro studies of potential co-medication interactions.

Cisapride is a prokinetic drug that is widely used to facilitate gastrointestinal tract motility. Structurally, cisapride is a substituted piperidinyl benzamide that interacts with 5-hydroxytryptamine-4 receptors and which is largely without central depressant or antidopaminergic side-effects. The aims of this study were to investigate the metabolism of cisapride in human liver microsomes and to determine which cytochrome P-450 (CYP) isoenzyme(s) are involved in cisapride biotransformation. Additionally, the effects of various drugs on the metabolism of cisapride were investigated. The major in vitro metabolite of cisapride was formed by oxidative N-dealkylation at the piperidine nitrogen, leading to the production of norcisapride. By using competitive inhibition data, correlation studies and heterologous expression systems, it was demonstrated that CYP3A4 was the major CYP involved. CYP2A6 also contributed to the metabolism of cisapride, albeit to a much lesser extent. The mean apparent K(m) against cisapride was 8.6+/-3.5 microM (n = 3). The peak plasma levels of cisapride under normal clinical practice are approximately 0.17 microM; therefore it is unlikely that cisapride would inhibit the metabolism of co-administered drugs. In this in vitro study the inhibitory effects of 44 drugs were tested for any effect on cisapride biotransformation. In conclusion, 34 of the drugs are unlikely to have a clinically relevant interaction; however, the antidepressant nefazodone, the macrolide antibiotic troleandomycin, the HIV-1 protease inhibitors ritonavir and indinavir and the calcium channel blocker mibefradil inhibited the metabolism of cisapride and these interactions are likely to be of clinical relevance. Furthermore, the antimycotics ketoconazole, miconazole, hydroxy-itraconazole, itraconazole and fluconazole, when administered orally or intravenously, would inhibit cisapride metabolism.