User:Mkeomani/Grapefruit–drug interactions

Lead
(Working on improving an existing article - grammar and verification)

Editing To Do List:

*** Mechanisms of Action needs work***


 * 1) Metabolizing enzymes transform these drugs into metabolites. The primary purpose for drug metabolism is to detoxify, inactivate, solubilize and eliminate these drugs.  As a result, the amount of the drug in its original form that reaches systemic circulation is reduced due to this first-pass metabolism. FROM Grapefruit–drug interactions
 * 2) As a result, many drugs are impacted by consumption of citrus juice. When the metabolizing enzyme is inhibited, less of the drug will be metabolized by it in the epithelial cells. A decrease in drug metabolism means more of the original form of the drug could pass unchanged to systemic blood circulation.  An unexpected high dose of the drug in the blood could lead to fatal drug toxicity. ALSO FROM Grapefruit–drug interactions
 * 3) Both the Pgp and CYP3A4 may act synergistically as a barrier to many orally administered drugs. Therefore, their inhibition (both or alone) can markedly increase the bioavailability of a drug.  FROM SAME ARTICLE AS ABOVE
 * 4) Look into duration of action (metabolism interaction)
 * 5) Find an appropriate medical citation for the apple juice section in "other fruits & vegetables"
 * 6) Verify if cisapride is a CYP3A4 inhibitor - Just checked Lexi: it's not, GJ (CYP3A4 inhibitor) is C/I w/ cisapride - investigate citation and rephrase sentence!
 * 7) Clarify "levothyroxine" sub-section in the list of incomplete drugs - someone in talks points out the limitations of the cited study
 * 8) Clean up the table, it's lacking
 * 9) To be honest, I think the "Other interactions" could be re-organized by drug class - project can undertake while adding more info in the antihistamine and CCB sec

Article body
A. Paśko, P., Rodacki, T., Domagała-Rodacka, R., Palimonka, K., Marcinkowska, M., & Owczarek, D. (2017). Second generation H1 - antihistamines interaction with food and alcohol-A systematic review. Biomedicine & pharmacotherapy = Biomedecine & pharmacotherapie, 93, 27–39. https://doi.org/10.1016/j.biopha.2017.06.008

Notes from review (TO BE FILTERED & ORGANIZED):

- Cmax reduced by 33% and AUC by 24% (open-label, randomized, 2-wat x-over study) Crean et al. 2007 - probs not relevant to wiki BUT in discussion sec: effect of GJ on vilastine (open-label, randomized, two-way crossover study in 12 healthy adults) 20mg Tab bilastine administered once w/ 240 ml H2O & once w/ 240 ml of GJ. Co-administration = reduced bilastine exposure hence reducted by 33% and 24%.

---> Rodriguez et al. effects of GJ consumption on bioavailability of bilastine ... anyways cmax & AUC related to down-regulation of cell transport activity in intestinal mucosa, the organic anion transporting polypeptides (OATP1A2) as well as by the fruit influence on P-gp activity as bilastine is a substrate of P-glycoprotein.

- No effect on PK parameters (tabs) (non-blinded, randomized, single-dose 4-way xover Banfield et al., 2022) - probs not relevant? --> PK after single PO dose 5mg desloratadine taken without & w/ GJ (pre-tx w/ 240 ml of double-strength juice TID x 2 ds prior to administration of studied drug, plus the same amount simultaneously with and 2 hr after, the drug dose). The bioavailability of desloratadine was unaffected by GJ intake. The mean Tmax and T1/2 of deloratadine and its metabolite were not appreciably affected by administration of GJ. "No clinically significant change in ECG parameters following coadministration of GJ w. desloratadine compared with drug given alone were found"

--> more from Banfield et al. (non-blinded, randomized, single-dose 4-way x-over study) 23 healthy subjects investigated changed in PK after single PO dose of fexofenadine 60 mg taken without and with GJ (pre-tx w. 240 ml of double-strength juice TID for 2 ds prior...) = the bioavailability of fexofenadine was reduced by GJ by 30%. There were no clinically significant changes in ECG parameters following coadministration of GJ w. fexofenadine compared with drug given alone.

---> Desloratadine is not a substrate of OATP-A. (although p-gp cannot be exclused). BUT Wang et al., showed desloratadine not to be a substrate for P-gp. The ultimate extent of absorption when given concomitantly with grapefruit juice may depend on the relative degree to which p-gp and OATP are inhibited but as desloratadine in not the substrate for these transporters such interaction wasn't observed. In addition, desloratadine is a substrate for CYP2C8 (not CYP1A2/2A6/2C9/2C19/2E1/2D6/3A - which may be inhibited by citrus juices active compounds). CYP2C8 - might contribute to hepatic clearance (mainly) of drug, whereas the contribution of citrus fruit might be more pronounced during 1st-pass metab in gut, buuuut as only very limited amounts of CYP2C8 mRNA and no expression of the protein have been detected in human duodenum & small intestine, the prescence of CYP2C8 in the intestine is probs very limited, and significant in vivo effects of GJ on this enzyme seems unlikely.

- Decreased excretion of urinary desalkylebastine (metabolit of ebastine) no data Gervasini et al. 2006 --> study w/ 61 healthy subjects (look into - adults..? kids??) given a single 20 mg ebastine found that urinary excretion of desalkylebastine, the ebastine metabolite, was reduced by about 25% by grapefruit juice when 250 ml of GJ was administered TID for 2 days before the ebastine, and together with the drug. Decreased eccretion of urinary desalkylebastine is consistent with the inhibition of CYP3A activity by grapefruit juice. Furthermore, CYP3A5*1 carriers showed 2-fold higher decrease in metabolite excretion values after GJ intake vs/compared w/ the CYP3A5*3/*3 genotype (check if this is poor metabolizer or extensive???). Thus subjects who express CYP3A5 could be more susceptible to influence of enzyme inhibitors, which might be of clinical relevance (I sure hope so). Authors also indicated that the observed effect can be associated with decrease of P-GP activity in the gut and/or renal tubular cells.

---> Dresser et al also evaluated duration of GJ effect on fexofenadine interaction in a randomized crossover study. 12 subjects received 300ml juice or HwO and fexofenadine (120 mg). GJ was given 0,2,4 or 10 h prior to fexofenadine. Duration of juice effect was highly variable among subjects. Decreased fexofenadine AUC and Cmax were observed up to 10 hr in 4 subjects.

---> They also estimated in a randomized 5-way c-over in 10 health subjects the PO PK of 120 mg fexofenadine assessed with H2O, 25% GJ, or normal-strength GJ, orange or apple juice (1.2 L over 3 hours). GJ, orange, and apple juice decreased the fexogenadine AUC, Cmax and urinary excretion values to 30-40% of those with H2O, with no change in the Tmax elimination half-life, renal clearance or urine volume. Change in fexofenadine AUC with juice varied between individuals. Diluted GJ (25%) caused a smaller reduction in the AUC of fexofenadine of 23%. Normal strength GJ, OJ and AJ decreased AUC of fexofenadine by 67%, 72%, & 77%, respectively. It was suggested that fruit juices and their constituents are more potent inhibitors of OATPs and P-GP activities which can reduce PO drug bioavailability.

- Diminished PO bioavailability + Cmax / decreased AUC/Cmax / normal-strength juice decreased AUC b 67% Cmax and urinary excretipon values, dilute grapefruit juice caused reduction in AUC by 23$ cmax & AUC reduced by 30%... consumption @ 2 hr before drug decreased AUC by 38%, ingested 4 h before drug had no effect. Significantly decreased AUC for: (R)-fexofenadine by 39%, (S)-fexofenadine by 52%, reduced amounts excreted into the urine for (R)-fexofenadine by 52%, (S)-fexofenadine by 61%... (Dresser et al. 2005) - look into, there's mention of OJ and apple juice ---> Dresser et al.: evaluation clinical relevance & MOA for 2 different volumes of GJ on reduction of fexofenadine bioavailability. GJ/H2O at normal (300 ml) or high (1200ml) was ingested concomitantly w/ 120 mg fexofenadine by 12 healthy volunteers subjected to a randomized 4-way crossover study. The 300ml volume of GJ decreased significantly the mean AUC & Cmax of fexofenadine to 58% and 53% respectively of those with the corresponding volume of water. The high volume of GJ (1200 ml) reduced these parameters to 36% and 33% respectively. The 1200 ml volume of GJ decreaed AUC >300ml in each subject by a constant amount. Concluded: GJ at a commonly consumed volume diminished the PO bioavailability of fexofenadine sufficiently to be pertinent clinically, likely by direct inhibition of uptake by OATP1A2. Much higher volume caused an additional modest effect, possibly due to reduced intestinal concentration and transit time of fexofenadine.

- Glaeser et al., in in vitro studies (2 transporters: MDR1 and OATP1A2 were evaluated) to determine impact of GJ on these functions. 12 healthy subjects received 300 ml of GJ ingested 0, 2, 4 h prior to fexofenadine administration. Concomitant ingestion of GJ and fexofenadine reduced fexofenadine AUC by 25% compared to fexofenadine with H2O (948 - 343 vs 1992 + 917 ng x h/ml) consumption of juice 2 h before the drug administration decreased AUC by 38%. IF ingested 4 h BF drug produced no effect. To evaluate a detailed mechanism of the observed interaction, Glaeser et al assessed influence of acute GJ intake on intestinal OATP1A2, MDR1 and CYP3A expression by obtaining diodenal biopsy samples from volunteer subjects who ingested GJ/water and suggested that dietary constituents such as GJ are likely to interact with, and modulate the activity of intestinal uptake transporters such as OATP1A2.

- Akamine et al. investigated GJ ingestion on PK of fexofenadine (60 mg racemic fexofenadine enantiomers) in 14 healthy subjects in a randomized, two-phase, open-label, x-over study. Juice significantly decreased AUC0 for R/S-fexofenadine by 39% and 52% respectively. Stillm GJ greatly reduced amount of (R)-(S) fexofenadine excreted into the urine by 52% and 61% respectively. Stereoselective PK of fexofenadine is associated with OATP2B1 mediated-transport, and GJ being an OATP2B1 inhibitor, significantly reduced the plasma concentration of fexofenadine enantiomers, exhibiting clinically moderate effects. The present results = changes in OATP2B1 activity by GJ may alter the steroselective PK of fexofenadine and that reduced intestinal OATP2B1 activity may affect stereoselectivity of fexofenadine,

- Loratadine is extensively metabolized in the liver (CYP 3A4), CYP 2D6 at 1st to active desloratadine (four times more potent than the parent compound), and then of 3-hydroxydesloratadine. Theoretically, grapefruit juice may increase the plasma concentration of loratadine as the substrate of the CYP450 3A4 enzymatic pathway. The proposed mechanism is inhibition of CYP 450 3A4-mediated 1st-pass metabolism in the gut wall by certain compounds present in GJ. Reported interactions with potent CYP450 3A4 drug inhibitors have produced substantial increased in the AUC for loratadine and descarboethoxyloratadine (active metabolite) without changes in overall safety profile of drug. (Clinical signifiance remains unknown).

- Concurrent use of rupatadine & GJ increased systemic exposure of rupatadine 3.5 x. Therefore, rupatadine should not be given together with GJ. (Solans et al.)