Effects of multiple-dose rifampicin 450 mg on the pharmacokinetics of fexofenadine enantiomers in Japanese volunteers.

WHAT IS KNOWN AND OBJECTIVE: Rifampicin is a potent inducer of P-glycoprotein (P-gp) and inhibitor of organic anion-transporting polypeptides (OATPs), with fexofenadine acting as a substrate for both mechanisms. Simultaneous administration of single- or multiple-dose rifampicin 600 mg significantly increases the concentrations of fexofenadine enantiomers by inhibiting OATP transporters. However, the effects of rifampicin 450 mg are unknown. Here, we evaluated the effects of multiple doses of rifampicin 450 mg on the pharmacokinetics of fexofenadine enantiomers in healthy Japanese volunteers. METHODS: In this randomized, two-phase, double-blind crossover study, 10 healthy volunteers received rifampicin 450 mg/day or placebo for 7 days. On day 7, fexofenadine 60 mg was co-administered simultaneously. RESULTS AND DISCUSSION: Rifampicin significantly increased the mean area under the plasma concentration-time curve (AUC) of (R)- and (S)-fexofenadine (3.10-fold and 3.48-fold, respectively) and decreased the renal clearance of (R)- and (S)-fexofenadine (0.40-fold and 0.47-fold, respectively), causing marked differences in the mean amounts of these enantiomers excreted into the urine in the rifampicin phase (P < 0.001). These results indicated that multiple doses of rifampicin 450 mg may be sufficient to inhibit the renal influx transporter and OATP-mediated hepatic uptake of both enantiomers. Moreover, these effects may be greater than the P-gp-inductive effects of rifampicin. Therefore, the interactive mechanism of multidose rifampicin may occur through a combination of OATP and P-gp transporters, thereby altering the pharmacokinetics of fexofenadine enantiomers. WHAT IS NEW AND CONCLUSIONS: In this study of rifampicin 450 mg, the interactive magnitude of the mean AUC values of fexofenadine enantiomers was higher than that observed in the previous study of rifampicin 600 mg, and no dose-dependent inhibitory effects of rifampicin were observed. These effects may be clinically significant in patients receiving fexofenadine and rifampicin.

Genetic polymorphisms and functional characterization of the 5'-flanking region of the human CYP2C9 gene: in vitro and in vivo studies.

OBJECTIVE: Genetic polymorphisms were identified in the 5'-flanking region of the human CYP2C9 gene, and their effects on the phenotype were evaluated on the basis of the luciferase reporter gene assay and the in vivo pharmacokinetics of phenytoin. METHODS: Genetic polymorphisms were screened by polymerase chain reaction-single-strand conformational polymorphism analysis, following sequencing with DNA samples obtained from 50 healthy volunteers and 133 adult epileptic patients. HepG2 hepatoma cells were cotransfected with various sequence patterns of 5'-flanking region-luciferase reporter gene constructs. Pharmacokinetic parameters of phenytoin in relation to the corresponding sequence patterns were estimated by the Bayesian method, and the results were compared with in vitro activities. RESULTS: Genetic analysis revealed the existence of 7 single nucleotide polymorphisms (SNPs). Allele frequencies of T-->C transition at position -1912 (T-1912C), C-1886G, C-1566T, G-1538A, C-1189T, G-982A, and A-162G were 0.019, 0.019, 0.077, 0.019, 0.579, 0.019, and 0.003, respectively. Some mutations occurred simultaneously, and a total of 6 sequence patterns (patterns 1-6) were observed. The luciferase reporter gene assay indicated that the presence of mutation(s) resulted in a reduction in luciferase activity of 41.4% (pattern 2) to 86.8% (pattern 5) compared with the activity of the wild-type construct. The calculated intrinsic clearance of phenytoin was also lower (up to a 40% reduction for pattern 2) when a mutation(s) was present. CONCLUSION: In addition to the two major mutations in the coding region (CYP2C9*2 and CYP2C9*3 ), mutations in the 5'-flanking region of the human CYP2C9 gene appear to contribute to the large interindividual variability in drug metabolism activity.

Pharmacokinetics of omeprazole (a substrate of CYP2C19) and comparison with two mutant alleles, C gamma P2C19m1 in exon 5 and C gamma P2C19m2 in exon 4, in Japanese subjects.

The pharmacokinetic profile of omeprazole was examined in 27 healthy Japanese volunteers, and the results were analyzed in relation to genotype for the two mutations, CgammaP2C19m1 in exon 5 and CgammaP2C19m2 in exon 4, associated with the poor metabolizer phenotype. Of the 27 individuals analyzed, 10 were homozygous for the wild-type (wt) allele in both exon 5 and exon 4 (wt/wt; 37.0%, pattern GI), five were heterozygous for the CgammaP2C19m1 (wt/m1; 18.5%, G2), five were heterozygous for the CgammaP2C19m2 (wt/m2; 18.5%, G3), two were heterozygous for the two defects (m1/m2; 7.4%, G4), and five were homozygous for the CgammaP2C19m1 (m1/m1; 18.5%, G5). The allele frequencies of the m1 and m2 mutation were 0.31 and 0.13, respectively. A correlation between the rate of metabolism of omeprazole and genotype was observed. The mean clearance values of omeprazole in patterns G1, G2, G3, G4, and G5 were 1369.0, 332.7, 359.0, 70.8, and 89.5 ml/hr/kg, respectively. The relative area under the serum concentration-time curve (AUC) ratio of omeprazole to 5-hydroxyomeprazole in patterns G1, G2, G3, G4, and G5 was 1:2.8:3.4:16:17.2. A similar relation was observed in the omeprazole/5-hydroxyomeprazole serum concentration ratio, determined 3 hours after drug intake (1:3:4:18.8:20.3). There were significant (p < 0.05 to 0.01) differences in the disposition kinetics of omeprazole between the subjects with patterns G1, G2, and G3 and the subjects with patterns G4 and G5. The results indicate that the 5-hydroxylation pathway of omeprazole is clearly impaired in subjects with m1/m2 and m1/m1.

Drug interactions of zonisamide with phenytoin and sodium valproate: serum concentrations and protein binding.

The influence of co-medication with zonisamide (ZNS) on the serum concentration and protein binding of phenytoin (PHT) and sodium valproate (VPA) was studied in 21 pediatric patients. No significant correlation between the daily ZNS dose, and total serum concentrations, free concentrations or free fractions (FF) of PHT or VPA was observed. The patient study showed that changes in the FF of PHT and VPA were correlated more closely with the serum protein and bilirubin levels than changes in the ZNS dosage. An in vitro study revealed that the addition of ZNS caused decreases in the FF of PHT and VPA. However, these decreases were within the range of measurement error and were negligible. In conclusion, no significant effect of ZNS on the serum concentration or protein binding of PHT or VPA was demonstrated.

Evaluation of the therapeutic range of whole blood cyclosporin concentration in the treatment of psoriasis.

Cyclosporin (CyA) trough levels in whole blood in 17 patients receiving CyA for the treatment of severe psoriasis were measured by fluorescence polarization immunoassay (FPIA) employing a specific monoclonal antibody. Clinical success was defined as a PASI score reduction greater than or equal to 75% (group A), partial success by a PASI score reduction of 60%-74% (group B), and insufficient efficacy by a PASI score reduction of less than 60% (group C). Nine of the 17 patients given CyA (53%) exhibited an improvement rate of > or = 75% in the PASI score within 8 weeks of the initiation of treatment. At 8 weeks of treatment the values for the daily dose and whole blood trough CyA concentration were both significantly higher in group A than in group C, daily dose (3.6 +/- 1.0 vs. 2.3 +/- 0.4 mg/kg/day, respectively) and whole blood concentration (141.3 +/- 46.0 vs. 79.7 +/- 19.0 ng/ml). Throughout the study period, during an average observation period of 30 weeks, 13 of the 17 patients (76%) achieved a reduction rate of > or = 75% in the PASI score. In these 13 patients in whom psoriasis lesions cleared satisfactorily the values for the mean daily CyA dose, and whole blood trough levels were 2.4 mg/kg/day and 94.8 ng/ml, respectively. The improvement rate was significantly higher when the CyA trough level was above, rather than below, 100-140 ng/ml within the first 8 weeks, although a lower CyA dose and/or whole blood level was effective in maintaining the reduced PASI score in the subsequent phase. The most important side-effect was mild hypertension in 7 of the 17 patients (41%), however, the onset of hypertension in these patients varied from 30-100 days after the initiation of treatment. Antihypertensive drug therapy and/or dose reduction resulted in a significant decrease, from 166 +/- 17/100 +/- 7-140 +/- 6/84 +/- 10 mmHg, of the CyA-induced hypertension. The relationship between the time course of the duration of improved PASI score and the whole blood concentration of CyA was observed, which suggests that the changes in drug effects were correlated with changes in whole blood levels. During the study period we experienced recurrences in 2 patients after the tapering or withdrawal of CyA treatment. In these 2 patients the relapse may have been due, in part, to the sharp decrease in whole blood concentration secondary to partial noncompliance. Measurement of whole blood CyA trough level is the only method for assessing the patient's noncompliance. Contrary to previous reports we confirmed that the measurement of CyA concentration in whole blood was useful for monitoring the effects in patients with psoriasis.

Pharmacokinetic study of zonisamide in patients undergoing brain surgery.

To test whether the concentration of the anticonvulsant zonisamide in erythrocytes reflects the brain concentration and the clinical response of the drug, its pharmacokinetics were studied in nine patients undergoing surgery for brain tumour. Erythrocyte, total and free serum concentrations in samples drawn on the day of brain surgery were compared with levels on a day after the operation. In three patients zonisamide and its major metabolite, 2-sulphamoylacetylphenol, were also analysed in urine. The area under the curve of the free and the erythrocyte concentration did not differ between the two study phases whereas the area under the curve of the total serum concentration was significantly lower on the day of the operation, and this was associated with significant increases in total clearance (15.4 compared with 12.7 mL kg-1 h-1, P < 0.05, n = 9) and renal clearance (5.4 compared with 3.3 mL kg-1 h-1, P < 0.05, n = 3), and non-significant change in non-renal clearance (7.7 on the day of operation compared with 8.4 mL kg-1 h-1 on the post-operation day, n = 3). Zonisamide distribution was also altered by the operative procedure, as evidenced by a higher volume of distribution (1.48 compared with 0.87 L kg-1, P < 0.05, n = 9). The binding of zonisamide was characterized on both days. Zonisamide binding to erythrocytes seemed to occur by two processes: a saturable process and a non-saturable linear process. The maximum binding capacity to erythrocytes (31.6 vs 29.7 micrograms mL-1) did not differ on the two days; however, increases in the dissociation binding constant (+28%) and the proportionality constant (+24%) were observed on the day of the operation, suggesting that the zonisamide concentration in erythrocytes was greater on the day of the operation. Brain surgery appears to be one of the possible factors altering the rate of elimination of zonisamide and the uptake of the drug by erythrocytes.

Pharmacogenetic characterization of sulfasalazine disposition based on NAT2 and ABCG2 (BCRP) gene polymorphisms in humans.

The role of breast cancer resistance protein (BCRP), an efflux ABC transporter, in the pharmacokinetics of substrate drugs in humans is unknown. We investigated the impact of genetic polymorphisms of ABCG2 (421C>A) and NAT2 on the pharmacokinetics of sulfasalazine (SASP), a dual substrate, in 37 healthy volunteers, taking 2,000 mg of conventional SASP tablets. In ABCG2, SASP AUC(0-48) of C/C, C/A, and A/A subjects was 171 +/- 85, 330 +/- 194, and 592 +/- 275 microg h/ml, respectively, with significant differences among groups. In contrast, AUC(0-48) of sulfapyridine (SP) tended to be lower in subjects with the ABCG2-A allele as homozygosity. In NAT2, AUC(AcSP)/AUC(SP) was significantly higher in rapid than in intermediate and slow acetylator (SA) genotypes. We successfully described the pharmacokinetics of SASP, SP, and N -acetylsulfapyridine (AcSP) simultaneously by nonlinear mixed-effects modeling (NONMEM) analysis with regard to both gene polymorphisms. The data indicate that SASP is a candidate probe of BCRP, particularly in its role in intestinal absorption.

SLCO1B1 (OATP1B1, an uptake transporter) and ABCG2 (BCRP, an efflux transporter) variant alleles and pharmacokinetics of pitavastatin in healthy volunteers.

To investigate the contribution of genetic polymorphisms of SLCO1B1 and ABCG2 to the pharmacokinetics of a dual substrate, pitavastatin, 2 mg of pitavastatin was administered to 38 healthy volunteers and pharmacokinetic parameters were compared among the following groups: 421C/C(*)1b/(*)1b (group 1), 421C/C(*)1b/(*)15 (group 2), 421C/C(*)15/(*)15 and 421C/A(*)15/(*)15 (group 3), 421C/A(*)1b/(*)1b (group 4), 421A/A(*)1b/(*)1b (group 5), and 421C/A(*)1b/(*)15 (group 6). In SLCO1B1, pitavastatin area under plasma concentration-time curve from 0 to 24 h (AUC(0-24)) for groups 1, 2, and 3 was 81.1+/-18.1, 144+/-32, and 250+/-57 ng h/ml, respectively, with significant differences among all three groups. In contrast to SLCO1B1, AUC(0-24) in groups 1, 4, and 5 was 81.1+/-18.1, 96.7+/-35.4, and 78.2+/-8.2 ng h/ml, respectively. Although the SLCO1B1 polymorphism was found to have a significant effect on the pharmacokinetics of pitavastatin, a nonsynonymous ABCG2 variant, 421C>A, did not appear to be associated with the altered pharmacokinetics of pitavastatin.

Therapeutic drug monitoring services at Kyushu University Hospital in Japan.

Quantitative evaluation of the therapeutic drug monitoring services (TDMS) provided in Kyushu University Hospital from August 1981 to April 1989 was performed. Since 1982, the annual number of assay requests was about 4300-4400, but the annual number of clinical pharmacokinetic consultation services (CPCS) showed a tendency to increase. Antiepileptics were the drugs for which CPCS were most often performed (26.3 percent of the population given drugs for which TDMS was available); digoxin, lithium, and theophylline followed. Preparation of one consultation required 1.5-2.5 hours. Our TDMS team consists of eight members. In 1988, the average time per week spent for CPCS and TDMS was 8.2 and 11.3 hours per member, respectively. Thus, the number of pharmacists performing CPCS and TDMS was 1.2 and 1.7 full-time equivalents, respectively.

Analysis of the factors influencing anti-epileptic drug concentrations--carbamazepine.

The factors that influence carbamazepine (CBZ) serum concentrations and level:dose ratios were evaluated retrospectively on 83 consecutive routine CBZ determinations from chronically treated epileptic patients. The total level:dose ratio was lower when the drug was given in combination with phenytoin or with phenytoin plus other anti-epileptic drugs (AED) than when CBZ was given alone. The free level:dose ratio was also decreased during concomitant treatment with phenytoin. In spite of alterations to both level:dose ratios, the free fraction of CBZ was unaltered when in combination with other AEDs. There were statistically significant correlations between the CBZ dose (mg/kg/day) and the serum levels:total (r = 0.372, P less than 0.001) and free (r = 0.335, P less than 0.005). However, the wide scatter in the CBZ serum levels at each given dose were such that the relationships had no predictive values. Stepwise multivariate regression analysis (MVR) was also performed. A comparison of the normalized regression coefficients indicated that the CBZ dose, PHT dose, the time elapsed from the previous dose, the albumin concentration and the triglyceride levels were important factors which influence the CBZ total serum level. Similar analysis for the CBZ free serum level, gave a multiple correlation coefficient of 0.838, which indicates that 70.3% of the variance was explained by nine independent variables. The major factors that significantly affected the free serum level of CBZ were CBZ dose, PHT dose, the time elapsed from the previous dose and the triglyceride and albumin levels. Our observations indicate that it may be possible to predict reliably the CBZ serum concentrations for individual patients before institution of CBZ therapy.

Analysis of the factors influencing anti-epileptic drug concentrations--valproic acid.

The factors that influence valproic acid (VPA) serum concentrations and level:dose ratios were evaluated, retrospectively, on 51 consecutive routine VPA determinations from 50 chronically treated epileptic patients. The influence of co-medicated anti-epileptic drugs (phenytoin, phenobarbital, carbamazepine), alone or in combination, on total and free levels of VPA was studied. Furthermore, the possible influence of certain physiological and/or pathophysiological factors (age, weight, sex and clinical laboratory data) was considered. The total level:dose ratio was lower when VPA was given in combination with phenytoin or with carbamazepine than when VPA was given alone. The free level:dose ratio also decreased during concomitant treatment with phenytoin. The free fraction of VPA was unaltered when in combination with phenytoin or with carbamazepine, whereas it was decreased by a combination with phenytoin plus carbamazepine. As a whole, strong, positive, correlations existed between the VPA dose (mg/kg/day) and the total and free serum levels of VPA in the range of less than 15 mg/kg/day, but both levels of VPA tended to flatten out at the range of more than 15 mg/kg/day. These findings should therefore be considered when defining dosage regimens or interpreting serum drug concentrations. Stepwise multivariate regression analysis (MVR) showed that the VPA dose, simultaneous carbamazepine intake, serum glutamic oxalacetic transaminase (SGOT) and serum albumin concentration were important determinants of VPA serum concentrations.

Influence of additional therapy with zonisamide (Excegran) on protein binding and metabolism of carbamazepine.

The influence of comedication with zonisamide (ZNS) on protein binding and carbamazepine (CBZ) metabolism was studied in 16 pediatric epileptic patients. Correlations were evaluated between ZNS daily dose and individual change of level per dose ratio (L/D ratio), free fraction, and carbamazepine-10,11-epoxide/CBZ level ratio (CBZE/CBZ). Statistical significant negative correlation was observed between L/D ratio and ZNS daily dose. Despite alteration in the L/D ratio, the free fraction of CBZ was unaltered in combination with ZNS. To assess the effect of addition of ZNS on CBZ metabolism, the CBZE/CBZ level ratio was compared; this ratio showed a tendency to increase with increase in ZNS dose. Consequently, ZNS is considered to have a significant effect on CBZ metabolism but not on protein binding.

Phenytoin intoxication induced by fluvoxamine.

A patient had phenytoin intoxication after administration of fluvoxamine, a selective serotonin reuptake inhibitor. The serum concentration of phenytoin increased dramatically from 16.6 to 49.1 microg/mL when fluvoxamine was coadministered, although the daily dosage of phenytoin and other drugs had not changed. During phenytoin and fluvoxamine treatment, ataxia, a typical side effect of phenytoin, was observed. The genotypes of CYP2C9 and 2C19, the enzymes responsible for phenytoin metabolism, were homozygous for the wild-type alleles (CYP2C9*1/*1 and 2C19*1/ *1). The interaction may be a result of inhibition of both CYP2C9 and 2C19 by fluvoxamine.

Instability of standard calibrators may be involved in overestimating vancomycin concentrations determined by fluorescence polarization immunoassay.

Fluorescence polarization immunoassay (FPIA) is widely used to determine serum vancomycin concentrations, and it has been shown to over-estimate vancomycin concentrations in sera from renally impaired patients. This phenomenon has generally been thought to result from interference by vancomycin crystalline degradation products (CDP-1). In this study, we confirmed that serum vancomycin concentrations in various patients determined by FPIA were higher than those determined by high-performance liquid chromatography (HPLC) or enzyme multiplied immunoassay (EMIT). However, the quantitative differences in the serum vancomycin concentrations determined by FPIA versus HPLC were higher than the CDP-1 concentrations, even when the cross-reactivity of FPIA to CDP-1 is assumed to be 100%. When the vancomycin calibrators for FPIA were stored at 4 degrees C for 30 days, their concentrations determined by FPIA and HPLC decreased by 14 and 20%, respectively, and CDP-1 corresponding to 20% of primary vancomycin was formed. When stored at 25 degrees C, the degradation of vancomycin was more marked. We concluded that not only the cross-reactivity of FPIA to CDP-1 but also the instability of calibrators may cause the overestimation of serum vancomycin concentrations determined by FPIA.

Pharmacoepidemiological study on adverse reactions of antiepileptic drugs.

The relationship between the occurrence of side effects (SEs) and drug factors, such as antiepileptic drugs (AEDs), daily dose, duration of treatment, drug combination pattern, total and free serum concentrations, metabolite per parent level ratio as an index of metabolism ability, and co-medicated drugs except AEDs were evaluated in 227 outpatients with epilepsy. The possible influences of certain physiological and/or the pathophysiological factors were also evaluated. SEs with 19 clinical signs were observed in 66.1% of all patients. There was no definite dose- or serum concentration-dependent increase in the incidence of SEs. Stepwise discriminant function analysis revealed that benzodiazepines (BZN) polytherapy with AEDs produced a higher incidence of somnolence and general fatigue than did any other AED or drug combination. The effects of various drug combination patterns on the incidence of SEs were also evaluated on the basis of observed frequencies. The incidence of somnolence was significantly higher in patients taking phenytoin (PHT) plus carbamazepine (CBZ) therapy, and in patients taking BZN plus either PHT, phenobarbital (PB) or CBZ therapy compared with patients taking either PHT, PB or CBZ therapy. Other responsible drug combination patterns were PHT plus valproic acid (VPA) therapy for mental function impairment, acetazolamide (AZM) polytherapy with PB or PHT for dry mouth, and CBZ plus BZN therapy for constipation. In this study, the stratifying points (occurrence limits) of SEs were detected in various variables such as the number of prescribed drugs, daily dose and serum concentrations. Interestingly, these limits are within the commonly accepted "therapeutic range" or "usual daily dose," and some of these limits shifted down when another AED was co-medicated.(ABSTRACT TRUNCATED AT 250 WORDS)

Genetic polymorphism of the CYP2C subfamily and excessive serum phenytoin concentration with central nervous system intoxication.

The authors report on a Japanese adult male patient with a long history of partial seizures that were poorly controlled by conventional doses of phenytoin and other drugs. His treatment was complicated by toxic symptoms and an excessive serum phenytoin concentration, 32.6 microg/mL at a dose of 187.5 mg/day. Polymerase chain reaction-restriction fragment length polymorphism analysis disclosed heterozygosity involving cytochrome P450 subfamilies 2C9 (*1/*3) and 2C19 (*1/*3). Currently, it is generally accepted that the former mutation is responsible for the CYP2C9 poor metabolizer phenotype. Pharmacokinetic parameters were estimated by a kinetic analysis, MULTI, using 17 observed dose-concentration data sets: a lower Vmax (5.6 mg/kg/day) and a higher Km (11.5 microg/mL) were observed. Although phenytoin is metabolized predominantly by CYP2C9 with a minor contribution of CYP2C19, patients with the Leu359 variant should be monitored closely when treated with a moderate to high daily dose of phenytoin.