Itraconazole, gemfibrozil and their combination markedly raise the plasma concentrations of loperamide
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Loperamide is biotransformed in vitro by the cytochromes P450 (CYP) 2C8 and 3A4 and is a substrate of the P-glycoprotein efflux transporter. Our aim was to investigate the effects of itraconazole, an inhibitor of CYP3A4 and P-glycoprotein, and gemfibrozil, an inhibitor of CYP2C8, on the pharmacokinetics of loperamide.
In a randomized crossover study with 4 phases, 12 healthy volunteers took 100 mg itraconazole (first dose 200 mg), 600 mg gemfibrozil, both itraconazole and gemfibrozil, or placebo, twice daily for 5 days. On day 3, they ingested a single 4-mg dose of loperamide. Loperamide and N-desmethylloperamide concentrations in plasma were measured for up to 72 h and in urine for up to 48 h. Possible central nervous system effects of loperamide were assessed by the Digit Symbol Substitution Test and by subjective drowsiness.
Itraconazole raised the peak plasma loperamide concentration (Cmax) 2.9-fold (range, 1.2–5.0; P<0.001) and the total area under the plasma loperamide concentration-time curve (AUC0-∞) 3.8-fold (1.4–6.6; P<0.001) and prolonged the elimination half-life (t½) of loperamide from 11.9 to 18.7 h (P<0.001). Gemfibrozil raised the Cmax of loperamide 1.6-fold (0.9–3.2; P<0.05) and its AUC0-∞ 2.2-fold (1.0–3.7; P<0.05) and prolonged its t½ to 16.7 h (P<0.01). The combination of itraconazole and gemfibrozil raised the Cmax of loperamide 4.2-fold (1.5–8.7; P<0.001) and its AUC0-∞ 12.6-fold (4.3–21.8; P<0.001) and prolonged the t½ of loperamide to 36.9 h (P<0.001). The amount of loperamide excreted into urine within 48 h was increased 3.0-fold, 1.4-fold and 5.3-fold by itraconazole, gemfibrozil and their combination, respectively (P<0.05). Itraconazole, gemfibrozil and their combination reduced the plasma AUC0–72 ratio of N-desmethylloperamide to loperamide by 65%, 46% and 88%, respectively (P<0.001). No significant differences were seen in the Digit Symbol Substitution Test or subjective drowsiness between the phases.
Itraconazole, gemfibrozil and their combination markedly raise the plasma concentrations of loperamide. Although not seen in the psychomotor tests used, an increased risk of adverse effects should be considered during concomitant use of loperamide with itraconazole, gemfibrozil and especially their combination.
KeywordsCYP2C8 CYP3A4 Gemfibrozil Itraconazole Loperamide Pharmacokinetics
We thank Mr. Mikko Neuvonen, MSc, Mr. Jouko Laitila, Mrs. Kerttu Mårtensson, Mrs. Eija Mäkinen-Pulli and Mrs. Lisbet Partanen for skillful assistance in performing this study and drug analyses. This study was supported by grants from the Helsinki University Central Hospital Research Fund and Sigrid Juselius Foundation. Experiments comply with the current laws, inclusive of ethics approval.
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