No Effect of Levothyroxine and Levothyroxine-Induced Subclinical Thyrotoxicosis on the Pharmacokinetics of Sorafenib in Healthy Male Subjects.

BACKGROUND: Patients receiving the multikinase inhibitor sorafenib for locally recurrent or metastatic, progressive, differentiated thyroid carcinoma (DTC) refractory to radioactive iodine often receive concomitant levothyroxine for thyrotropin (TSH) suppression. In the Phase 3 DTC trial (DECISION), sorafenib exposure was approximately twofold higher than that observed in other cancers. This study assessed sorafenib pharmacokinetics without and with concomitant levothyroxine to examine whether a levothyroxine interaction or levothyroxine-induced subclinical thyrotoxicosis results in increased sorafenib exposure in patients with DTC. METHODS: This was an open-label, two-period sequential treatment study in healthy male subjects. In period 1, day 1, subjects received a single oral dose of sorafenib 400 mg, followed by a minimal 10-day washout. In period 2, day 1, levothyroxine 300 µg was administered orally once daily (q.d.) for 14 days. After 10 days, a single oral concomitant dose of sorafenib 400 mg was given. Blood samples for sorafenib pharmacokinetic analyses were obtained pre-dose and at time points up to 96 hours after sorafenib dosing. Samples for thyroid tests were collected before and after levothyroxine dosing. RESULTS: Twenty-five subjects completed the study and were evaluable for pharmacokinetic analysis. Levothyroxine 300 µg q.d. was well tolerated and induced subclinical thyrotoxicosis, producing full suppression of TSH (M ± SD = 0.032 ± 0.027 mIU/L) and increased free thyroxine (from 0.94 ± 0.09 to 1.77 ± 0.33 ng/dL) and free triiodothyronine (from 2.87 ± 0.28 to 4.24 ± 0.66 pg/mL) levels by day 11 of period 2. The geometric mean (%CV) sorafenib maximum concentration (Cmax) without and with levothyroxine was 2.09 (68.1) and 1.78 (63.9) mg/L, respectively, with a corresponding geometric mean area under the curve of 68.1 (68.2) and 64.3 (66.3) mg·h/L. Median (range) time to Cmax was 4.00 (2.98-16.0) and 4.02 (1.98-36.0) hours, respectively. Mean (%CV) half-life was 24.0 (25.3) and 25.7 (21.0) hours. All study drug-related adverse events were mild and included headache and fatigue for sorafenib, and headache, increased alanine aminotransferase and glutamate dehydrogenase, fatigue, and nervousness for levothyroxine. CONCLUSIONS: Levothyroxine 300 µg q.d. for 14 days was well tolerated, induced subclinical thyrotoxicosis, and did not affect sorafenib pharmacokinetics. The findings suggest that concomitant use of levothyroxine with sorafenib is not likely responsible for the previously reported increase in sorafenib exposure in patients with DTC. However, the possible effects of long-term levothyroxine dosing were not assessed.

Renal excretion of clofarabine: assessment of dose-linearity and role of renal transport systems on drug excretion.

The renal excretion of clofarabine was studied in vitro in the isolated perfused rat kidney (IPK) model and in vivo in rats. Clofarabine excretion was studied at four doses (160, 800, 2000 and 4000microg) in the IPK, targeting perfusate levels of 2, 10, 25, 50microg/mL, respectively. Clofarabine (2microg/mL) was also co-perfused with known inhibitors of the, organic cation (cimetidine, ranitidine and tyramine) and organic anion (probenecid, ellagic acid) transport systems. Additionally, the effect of medications including, itraconazole, digoxin, fludarabine and cytarabine (Ara-C) on clofarabine excretion was, evaluated. Based on IPK results, in vivo studies were performed to assess the plasma, pharmacokinetics and urinary recovery of clofarabine (6.5mg/kg, IV) pretreatment, with cimetidine (250mg/kg, IV). Clofarabine clearance was non-linear in the IPK, although at concentrations that were approximately 10- to 100-fold higher than maximum concentrations observed in humans. Excretion ratio data indicated a shift from net, secretion (XR=1.2+/-0.33) to net reabsorption (XR=0.78+/-0.40) at the highest dose, tested. Clofarabine clearance was significantly reduced upon co-administration with, cimetidine (0.83+/-0.22-->0.32+/-0.058mL/min). In vivo data correlated with IPK results as clofarabine clearance decreased 61% (20.2-7.80mL/min/kg), upon co-administration with cimetidine in rats. The results suggest that clofarabine is a substrate for a cimetidine-sensitive organic cation transporter system in the kidney, presumably OCT2. The magnitude of the cimetidine-clofarabine interaction was similar, in IPK and in vivo, demonstrating the utility of the IPK model in characterizing renal, drug excretion and assessing potential drug-drug interactions.

Molecular alignment of rigid rods in nonrigid spherical pores.

We have investigated the orientation ordering of two shish-kebab chains confined by spherically harmonic potentials through Monte Carlo simulations and asymptotic analysis. The rigid rod is modeled as shish-kebab chains consisting of tangent hard spheres aligned in the same axis, and the harmonic potential is chosen to model nonrigid cavities. We first show that the interactions between a rod and the spherically harmonic potential are independent of chain orientation, indicating that the alignment of two confined rods arises from the excluded volume interactions alone. In the strong fields, the order parameter of two confined rods converges to different values, depending on the parity of chain length. From asymptotic order parameters, we find that the rods of odd-number beads rotate more freely even under the limiting strong confinement. However, the two rods of even-number beads are essentially trapped in a configuration of perpendicular alignment through intercalation of their central grooves. We attribute the dependence of the parity of chain length to the different locations of the center-of-mass in a rod for these two cases. Furthermore, we compare the shish-kebab chains with different rod models in the simulations, and utilize these models to explore the effect of the local rod smoothness on molecular alignment. Our findings suggest that increasing local rod smoothness enhances the rotational degree of freedom for confined rods, and the effect of local rod roughness emerges under strong enough applied potentials.