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Grapefruit juice greatly reduces the plasma concentrations of the oatp2b1 and cyp3a4 substrate aliskiren
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Grapefruit Juice Greatly Reduces the plasma
Concentrations of the OAtp2B1 and CYp3A4
substrate AliskirenT Tapaninen1, PJ Neuvonen1 and M Niemi1
In a randomized crossover study, 11 healthy volunteers
administered fexofenadine, a substrate of OATP1A2 and pos-
ingested 200 ml of grapefruit juice or water three times a day
sibly of OATP2B1.7,21,23,24 Because aliskiren is a substrate, and
for 5 days. On day 3, they ingested a single 150-mg dose of
grapefruit juice an inhibitor of both CYP3A4 and OATP2B1,
aliskiren. Grapefruit juice reduced aliskiren peak plasma
it is difficult to predict the possible effects of grapefruit juice
concentration (Cmax) by 81% (range, 42–91%, P < 0.001),
on aliskiren pharmacokinetics. Therefore, we investigated the
area under the plasma aliskiren concentration–time curve
effects of grapefruit juice on the pharmacokinetics of aliskiren.
(AUC)0–∞ by 61% (range, 15–72%, P < 0.001), and elimination
half-life (t½) from 26.1 to 23.6 h (P = 0.020). Therefore, Results
concomitant use of aliskiren and grapefruit juice is best
The intake of normal-strength grapefruit juice three times a
day markedly reduced the plasma concentrations of aliskiren
anThe peak plasma concentration (C
Aliskiren is a renin-inhibiting antihypertensive drug.1,2 When of aliskiren was reduced by 81% (range, 42–91%, P
orally administered, it has a bioavailability of only 2–3%, prob-
the area under the plasma aliskiren concentration–time curve
ably due in large part to poor absorption.2,3 Because aliskiren (AUC)0–∞ by 61% (range, 15–72%, P
< 0.001), and the amount of
is highly soluble in water and has a low permeability through aliskiren excreted into urine from 0 to 12 h (A
e) by 66% (range,
lipid membranes,1,2,4 influx transporters may be important 6–81%, P
< 0.001) The C
max of aliskiren occurred at
determinants of its absorption.5 Aliskiren is a substrate of two a later time point during the grapefruit-juice phase (median,
transporters expressed in the luminal membrane of small intes-
1 h) than during the water phase (median, 0.5 h) (P
= 0.016). The
tinal enterocytes: the organic anion–transporting polypeptide intake of grapefruit juice shortened the elimination half-life (t
2B1 (OATP2B1) influx transporter and the P-glycoprotein efflux of aliskiren from 26.1 to 23.6 h (P
= 0.020). Grapefruit juice had
transporter.4,6–8 Aliskiren is eliminated primarily via excretion of no significant effect on the renal clearance (CLR) of aliskiren,
the unchanged drug into the bile and, to a smal er extent, excre-
and there was no significant difference in plasma renin activity
tion into urine and oxidative biotransformation through cyto-
between the grapefruit-juice and water phases.
chrome P450 3A4 (CYP3A4).3 The hepatic uptake of aliskiren
is probably mediated by OATP2B1, and biliary excretion by Discussion
P-glycoprotein.4,7–9 Itraconazole, an inhibitor of CYP3A4 and These data show that grapefruit juice can have a profound effect
P-glycoprotein,10–13 and cyclosporine, an inhibitor of CYP3A4, on the pharmacokinetics of aliskiren, a substrate of OATP2B1
P-glycoprotein, and OATP2B1,13–16 have been shown to mark-
and CYP3A4.3,4 Three glasses a day of normal-strength grape-
edly increase the systemic exposure to aliskiren.17,18
fruit juice markedly decreased the C
max, AUC, and A
Grapefruit juice is a mechanism-based inhibitor of intesti-
aliskiren, consistent with a reduction in the bioavailability of the
nal CYP3A4 and enhances the oral bioavailability of many orally administered drug. The most likely mechanism of inter-
CYP3A4 substrates, as shown, for example, in the pioneering action is that grapefruit juice inhibits the OATP2B1-mediated
study involving felodipine.19,20 On the other hand, grapefruit absorption of aliskiren from gut lumen. To our knowledge, this
juice also inhibits intestinal OATP1A2 and OATP2B16,7,21–23 is the first study demonstrating that grapefruit juice may be a
and has been shown to reduce the bioavailability of orally clinically important inhibitor of OATP2B1.
1Department of Clinical pharmacology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland. Correspondence: M Niemi
Received 26 February 2010; accepted 25 April 2010; advance online publication 21 July 2010.
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| VOLUME 88 NUMBER 3 | sEptEMBER 2010
Grapefruit juice also slightly shortened the t
½ of aliskiren.
Similar to its effects on the pharmacokinetics of aliskiren,
In previous studies, repeated consumption of grapefruit juice grapefruit juice has been shown to markedly reduce the bio-
was shown to slightly prolong the t
½ of some CYP3A4 substrate availability of oral y administered fexofenadine (63% decrease in
drugs.25,26 Aliskiren undergoes enterohepatic circulation, char-
AUC) and celiprolol (87% decrease in AUC), probably by inhib-
acterized by double peaks in its plasma concentration curves.4,17 iting intestinal OATP influx transporters.12,21 Fexofenadine has
The shortened t
½ may have resulted from inhibition of the intes- been identified as a substrate of both OATP1A2 and OATP2B1,
tinal reabsorption of aliskiren during enterohepatic circulation. although one study failed to show OATP2B1-mediated trans-
The finding that the C
max of aliskiren occurred at a later time port of fexofenadine in transiently transfected HeLa cel s.21,23,24
point during the grapefruit-juice phase than during the water When directly compared, the OATP1A2-mediated influx of
phase is consistent with delayed absorption of aliskiren in asso-
fexofenadine was much greater than the OATP2B1-mediated
ciation with inhibition of intestinal OATP2B1.
influx.23 Celiprolol is a substrate of OATP1A2,27 but there are
no published studies on possible OATP2B1-mediated transport
In one study, concomitant ingestion of 300 ml of grapefruit
juice and fexofenadine decreased the AUC of fexofenadine by
52%.23 When 300 ml of grapefruit juice was ingested 2 h before
fexofenadine, the AUC was decreased by 38%, but when the juice
was ingested 4 h before fexofenadine, there was no effect.23 It is
likely that the effect of grapefruit juice on inhibition of OATP2B1
is of similar duration. Thus, it is possible that ingestion of only
a single 200–400 ml dose of grapefruit juice concomitantly or a
few hours before aliskiren would decrease the AUC of aliskiren
to an extent similar to that seen in the present study with inges-
tion of 200 ml of grapefruit juice three times daily.
In contrast to its effects on aliskiren, grapefruit juice was
shown to increase the AUC of the OATP2B1 substrates ator-
Geometric mean (90% confidence interval) plasma concentrations
vastatin (2.5-fold) and amiodarone (1.5-fold).25,28–30 Both
of aliskiren in 11 healthy volunteers. the volunteers ingested 200 ml of
atorvastatin and amiodarone are significantly metabolized by
grapefruit juice or water three times a day for 5 days and a single 150-mg dose of aliskiren on day 3, together with the first grapefruit-juice or water dose of
CYP3A4,13,30 and the inhibition of CYP3A4 by grapefruit juice is
the day. Inset depicts the same data on a semilogarithmic scale.
probably the main explanation for these interactions. Moreover,
table 1 Pharmacokinetic variables of and plasma renin activity response to a single 150-mg oral dose of aliskiren in 11 healthy
Water phase (control)
geometric mean ratio (90% Ci)
the volunteers ingested 200 ml of grapefruit juice or water three times a day for 5 days and a single 150-mg dose of aliskiren on day 3, together with the first grapefruit-juice or water dose of the day. Data are given as geometric means (90% CI), t
max as medians (range), and t
e, and plasma renin activity as mean values ± sD.A
e, amount excreted into urine within 12 h; AUC0–72 h, area under the plasma concentration–time curve from 0 to 72 h; AUC0–∞, area under the plasma concentration–time curve
from time 0 to ∞; baseline, before the administration of aliskiren; CI, confidence interval; CL/F, oral clearance; CLR, renal clearance; C
max, peak plasma concentration; k
rate constant; t
½, elimination half-life; t
max, time to C
aMean difference (90% CI).
VOLUME 88 NUMBER 3 | sEptEMBER 2010 | www.nature.com/cpt
max, AUC, and t
½ values of aliskiren in 11 healthy volunteers. the volunteers ingested 200 ml of grapefruit juice or water three times a
day for 5 days and a single 150-mg dose of aliskiren on day 3, together with the first grapefruit-juice or water dose of the day. AUC, area under the plasma concentration–time curve; C
max, peak plasma concentration; t
½, elimination half-life.
grapefruit juice has no significant effect on the pharmacokinet-
excluded because of noncompliance with the diet. Five women and
ics of the OATP2B1 substrates glyburide (glibenclamide) and six men completed the study. Their mean ± SD age was 22 ± 2 years
pravastatin, suggesting that OATP2B1 is not important for the (range, 20–28 years), mean height 178 ± 8 cm (range, 163–190 cm), and
mean weight 71 ± 10 kg (range, 55–92 kg). Each participant’s health
intestinal absorption of these compounds.22,24,25,31
was ascertained by medical history, clinical examination, and labora-
Several constituents of grapefruit juice—e.g., naringin, narin-
tory tests. Subjects with a systolic blood pressure <100 mm Hg were
genin, quercetin, bergamottin, and 6′,7′-dihydroxybergamottin—
not included in the study. None of the subjects was on any continuous
have been shown to inhibit OATP2B1 in vitro
.22 Naringin is medication, and none was a tobacco smoker.
considered the major constituent responsible for inhibition of study design.
The study protocol was approved by the Coordinating Ethics
OATP1A2 in vivo
,32 suggesting that it could also play an impor-
Committee of the Helsinki and Uusimaa Hospital District and by the
tant role in the inhibition of OATP2B1 by grapefruit juice in vivo
. National Agency for Medicines. In a randomized crossover study with two
In addition to the direct inhibition of OATP2B1 by grapefruit-
phases and a washout period of 2 weeks, the participants ingested either
juice constituents, other mechanisms may also contribute to the 200 ml of normal-strength grapefruit juice (Valio Greippitäysmehu; Valio,
Helsinki, Finland) or water three times a day at 8 am, 12 noon, and 8 pm for
interaction between grapefruit juice and aliskiren. Theoretical y, 5 days to ensure nearly maximal CYP3A4 inhibition and to investigate the
carbohydrates or organic acids present in grapefruit juice could possible effect of grapefruit juice on aliskiren elimination. On day 3, after
form a poorly absorbed complex with aliskiren. Also, grape-
an overnight fast, they ingested a single 150-mg dose of aliskiren (Rasilez;
fruit juice might alter intestinal fluid volume through an osmotic Novartis, Horsham, UK) with 200 ml of grapefruit juice or water at 8 am.
effect, the carbohydrates of grapefruit juice might delay stomach A standardized warm meal was served 4 h after aliskiren and standardized
light meals after 7 and 10 h. As a safety assessment, systolic and diastolic
emptying, or the acidic pH of grapefruit juice might affect the blood pressures were measured prior to and at 2, 4, 7, 9, 12, and 24 h after
solubility and ionization of aliskiren.
aliskiren ingestion. The measurements were made from the forearm, using
In previous studies, the P-glycoprotein and CYP3A4 inhibi-
an automatic oscil ometric blood pressure monitor (Omron M5-I; Omron
tors itraconazole and cyclosporine have been shown to raise the Healthcare Europe BV, Hoofddorp, The Netherlands), with the participant
AUC of aliskiren approximately sevenfold and approximately in the seated position. The participants were under direct medical supervi-
sion for 12 h after the administration of aliskiren. No significant changes
fivefold, respectively.10–15,17,18 Considering, as well, the marked in blood pressure were observed, nor were adverse effects reported. Use
effect of the OATP2B1 inhibitor grapefruit juice on aliskiren of grapefruit products was prohibited during the study, starting from 2
pharmacokinetics, it appears that aliskiren is very susceptible to weeks before the first day of administration of aliskiren. Use of all drugs
inhibition of both influx and efflux transporters, and possibly of was prohibited for 1 week, and use of apple juice, orange juice, and alcohol
for 2 days before aliskiren administration and for 72 h thereafter.
Timed ethylenediaminetetraacetic acid blood samples (5–15 ml each)
In this study, grapefruit juice had no significant effect on the were drawn before aliskiren ingestion and at various time points up to
renin activity response to a single dose of aliskiren in healthy vol-
72 h after ingestion. Plasma was separated within 30 min. Urine was col-
unteers. However, the pharmacodynamic response to aliskiren in lected for up to 12 h after aliskiren ingestion. The samples were stored at
patients with hypertension may be different from that in normo-
tensive individuals. The pharmacokinetics of aliskiren, however, is Determination of aliskiren concentrations and renin activity.
similar in hypertensive and normotensive individuals.2 Therefore, centrations of aliskiren in plasma and urine were quantified using an
clinicians should be aware that continuous use of grapefruit juice Applied Biosystems SCIEX QTrap LC/MS/MS system (Sciex Division of
may decrease the antihypertensive efficacy of aliskiren.
MDS, Toronto, Ontario, Canada).17,33 Acebutolol served as an internal
In conclusion, grapefruit juice greatly reduces the plasma con-
standard. The lower limit of quantification was 0.25 ng/ml for aliskiren
in plasma and 9 ng/ml for aliskiren in urine. The between-day coefficient
centrations of aliskiren, probably by inhibiting its OATP2B1-
of variation was ≤10% at relevant concentrations in plasma (n
= 6), and
mediated influx in the small intestine. The concomitant use of the intraday coefficient of variation was ≤4.8% at relevant concentra-
aliskiren and grapefruit juice is best avoided.
tions in urine (n
= 6). Plasma renin activity was measured using a radio-
immunoassay method (RENCTK; DiaSorin, Saluggia, Italy) at Medix
Twelve healthy volunteers participated in the study after
Pharmacokinetics and pharmacodynamics.
giving written informed consent, but one subject was subsequently
were characterized by estimating C
max, time to C
CliniCal pharmaCology & TherapeuTiCs
| VOLUME 88 NUMBER 3 | sEptEMBER 2010
rate constant (k
½, AUC0–72 h, AUC0–∞, oral clearance (CL/F), A
e, 9. Kullak-Ublick, G.A. et al
. Organic anion-transporting polypeptide B (OAtp-B)
and its functional comparison with three other OAtps of human liver.
R. Pharmacokinetic parameters were calculated by conven-
tional noncompartmental methods, using the MK-Model, version 5.0
, 525–533 (2001).
(Biosoft, Cambridge, UK). The terminal log-linear part of each con-
10. Olkkola, K.t., Backman, J.t. & Neuvonen, p.J. Midazolam should be avoided in
centration–time curve was identified visually. The k
patients receiving the systemic antimycotics ketoconazole or itraconazole.
by linear regression analysis of the log-linear part of the plasma drug
Clin. Pharmacol. Ther
, 481–485 (1994).
11. Wang, E.J., Lew, K., Casciano, C.N., Clement, R.p. & Johnson, W.W. Interaction
concentration–time curve. The t
½ was calculated from the equation
of common azole antifungals with p glycoprotein. Antimicrob. Agents
½ = ln2/k
e. The AUC values were calculated using a combination of
, 160–165 (2002).
the linear and log-linear trapezoidal rules with extrapolation to ∞, if
12. Lilja, J.J., Backman, J.t., Laitila, J., Luurila, H. & Neuvonen, p.J. Itraconazole
appropriate, by division of the last measured concentration by k
increases but grapefruit juice greatly decreases plasma concentrations of
CL/F was calculated from the equation CL/F = dose/AUC
celiprolol. Clin. Pharmacol. Ther
, 192–198 (2003).
13. Neuvonen, p.J., Niemi, M. & Backman, J.t. Drug interactions with lipid-lowering
R from the equation CLR = A
e/AUC0–12 h. Aliskiren pharmacody-
namics were characterized by estimating plasma renin activity at 4 and
drugs: mechanisms and clinical relevance. Clin. Pharmacol. Ther
14. Rao, U.s. & scarborough, G.A. Direct demonstration of high affinity
interactions of immunosuppressant drugs with the drug binding site of the
The data were analyzed using SPSS 17.0 (SPSS,
human p-glycoprotein. Mol. Pharmacol
, 773–776 (1994).
Chicago, IL). The results are expressed as geometric means with 90%
15. Kajosaari, L.I., Niemi, M., Neuvonen, M., Laitila, J., Neuvonen, p.J. &
Backman, J.t. Cyclosporine markedly raises the plasma concentrations of
max, AUC, CL/F, A
e, and CLR), mean ± SD (t
repaglinide. Clin. Pharmacol. Ther
, 388–399 (2005).
e, and plasma renin activity), or median with range (t
max). The C
16. Ho, R.H. et al
. Drug and bile acid transporters in rosuvastatin hepatic uptake:
R data were logarithmically transformed before
statistical analysis. Statistical comparisons between the grapefruit-juice
function, expression, and pharmacogenetics. Gastroenterology 130
and water phases were made using repeated-measures analysis of vari-
17. tapaninen, t., Backman, J.t., Kurkinen, K., Neuvonen, p.J. & Niemi, M.
ance with treatment phase as a within-subjects factor and treatment
Itraconazole, a p-Glycoprotein and CYp3A4 Inhibitor, markedly raises the
sequence as a between-subjects factor. The t
max data were compared
plasma concentrations and enhances the renin-inhibiting effect of aliskiren.
using the Wilcoxon signed-rank test. Differences were considered sta-
J. Clin. Pharmacol
. (2010); e-pub ahead of print 23 April 2010.
tistically significant if P
< 0.05. The number of subjects was estimated
18. Novartis. tekturna prescribing Information <http://www.pharma.us.novartis.
to be sufficient to detect a 50% difference in the AUC
com/product/pi/pdf/tekturna.pdf> (February 2010).
between the water and grapefruit-juice phases, with a power of 80%
19. Bailey, D.G., spence, J.D., Munoz, C. & Arnold, J.M. Interaction of citrus juices
with felodipine and nifedipine. Lancet 337
, 268–269 (1991).
20. Lown, K.s. et al
. Grapefruit juice increases felodipine oral availability in
humans by decreasing intestinal CYp3A protein expression. J. Clin. Invest
We thank Kaisa Kurkinen for aliskiren concentration measurements and
21. Dresser, G.K. et al
. Fruit juices inhibit organic anion transporting polypeptide-
Eija Mäkinen-pulli, Lisbet partanen, and Jouko Laitila for their skilled
mediated drug uptake to decrease the oral availability of fexofenadine.
assistance. this study was supported by grants from the Helsinki University
Clin. Pharmacol. Ther
, 11–20 (2002).
Central Hospital Research Fund (Helsinki, Finland) and the sigrid Jusélius
22. satoh, H. et al
. Citrus juices inhibit the function of human organic anion-
transporting polypeptide OAtp-B. Drug Metab. Dispos
, 518–523 (2005).
23. Glaeser, H. et al
. Intestinal drug transporter expression and the impact of
conFlict oF inteRest
grapefruit juice in humans. Clin. Pharmacol. Ther
, 362–370 (2007).
the authors declared no conflict of interest.
24. Nozawa, t., Imai, K., Nezu, J., tsuji, A. & tamai, I. Functional characterization
of pH-sensitive organic anion transporting polypeptide OAtp-B in human. J. Pharmacol. Exp. Ther
, 438–445 (2004).
2010 American society for Clinical pharmacology and therapeutics
25. Lilja, J.J., Kivistö, K.t. & Neuvonen, p.J. Grapefruit juice increases serum
concentrations of atorvastatin and has no effect on pravastatin.
1. Wood, J.M. et al
. structure-based design of aliskiren, a novel orally effective
Clin. Pharmacol. Ther
, 118–127 (1999).
renin inhibitor. Biochem. Biophys. Res. Commun
, 698–705 (2003).
26. Lilja, J.J., Kivistö, K.t., Backman, J.t. & Neuvonen, p.J. Effect of grapefruit juice
2. Vaidyanathan, s., Jarugula, V., Dieterich, H.A., Howard, D. & Dole, W.p. Clinical
dose on grapefruit juice–triazolam interaction: repeated consumption
pharmacokinetics and pharmacodynamics of aliskiren. Clin. Pharmacokinet
prolongs triazolam half-life. Eur. J. Clin. Pharmacol
, 411–415 (2000).
, 515–531 (2008).
27. Kato, Y., Miyazaki, t., Kano, t., sugiura, t., Kubo, Y. & tsuji, A. Involvement of
3. Waldmeier, F. et al
. Absorption, distribution, metabolism, and elimination of
influx and efflux transport systems in gastrointestinal absorption of celiprolol.
the direct renin inhibitor aliskiren in healthy volunteers. Drug Metab. Dispos
J. Pharm. Sci
, 2529–2539 (2009).
, 1418–1428 (2007).
28. Grube, M. et al
. Organic anion transporting polypeptide 2B1 is a high-
4. Vaidyanathan, s. et al
. pharmacokinetics of the oral direct renin inhibitor
affinity transporter for atorvastatin and is expressed in the human heart.
aliskiren in combination with digoxin, atorvastatin, and ketoconazole in
Clin. Pharmacol. Ther
, 607–620 (2006).
healthy subjects: the role of p-glycoprotein in the disposition of aliskiren.
29. seki, s., Kobayashi, M., Itagaki, s., Hirano, t. & Iseki, K. Contribution of organic
J. Clin. Pharmacol
, 1323–1338 (2008).
anion transporting polypeptide OAtp2B1 to amiodarone accumulation in
5. Wu, C.Y. & Benet, L.Z. predicting drug disposition via application of BCs:
lung epithelial cells. Biochim. Biophys. Acta 1788
, 911–917 (2009).
transport/absorption/ elimination interplay and development of a
30. Libersa, C.C. et al
. Dramatic inhibition of amiodarone metabolism induced by
biopharmaceutics drug disposition classification system. Pharm. Res
grapefruit juice. Br. J. Clin. Pharmacol
, 373–378 (2000).
31. Lilja, J.J., Niemi, M., Fredrikson, H. & Neuvonen, p.J. Effects of clarithromycin
6. Kobayashi, D., Nozawa, t., Imai, K., Nezu, J., tsuji, A. & tamai, I. Involvement
and grapefruit juice on the pharmacokinetics of glibenclamide. Br. J. Clin.
of human organic anion transporting polypeptide OAtp-B (sLC21A9) in pH-
, 732–740 (2007).
dependent transport across intestinal apical membrane. J. Pharmacol. Exp.
32. Bailey, D.G., Dresser, G.K., Leake, B.F. & Kim, R.B. Naringin is a major and
, 703–708 (2003).
selective clinical inhibitor of organic anion-transporting polypeptide 1A2
7. Niemi, M. Role of OAtp transporters in the disposition of drugs.
(OAtp1A2) in grapefruit juice. Clin. Pharmacol. Ther
, 495–502 (2007).
, 787–802 (2007).
33. tapaninen, t., Neuvonen, p.J. & Niemi, M. Rifampicin reduces the plasma
8. Fromm, M.F. Importance of p-glycoprotein at blood-tissue barriers. Trends
concentrations and the renin-inhibiting effect of aliskiren. Eur. J. Clin.
, 423–429 (2004).
, 497–502 (2010).
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Liite nro 6 Hallitus 24.1.2014 PALVELUHINNASTO 1.1.2014 lukien Hallitus 13.12.2013 24.1.2014 Kymenlaakson sairaanhoito- ja sosiaalipalvelujen kuntayhtymä PALVELUJEN HINNASTO 1.1.2014 LUKIEN SISÄLLYSLUETTELO Psykiatria Sosiaalipalvelut Kymenlaakson sairaalapalvelut Sädehoito PALVELUJEN TUOTTEISTUKSEN JA HINNOITTELUN PERIAATTEET 1.1.2014 alkaen Perusso
CURRICULUM VITAE JAMES GIORDANO, Ph.D. CURRICULUM VITAE JAMES J. GIORDANO 459 Old Town Ct Alexandria, VA 22314 703. 519-5276 DATE OF BIRTH 22 September 1959 CITIZENSHIP EDUCATION Grad. Certificate 2006 Loyola University, IL Bioethics and Health Policy Johns Hopkins University Neurotoxicology/Neuropathology City University of NY Biopsychology ( with di