Drug Interactions Notes

Drug Interactions

Objectives

  • To provide the knowledge required to identify, prevent and resolve predictable drug-drug interactions to optimize patient outcomes.
  • Explain the mechanisms of common drug interactions.
  • Determine potential drug interactions.
  • Develop an understanding of how to prevent or clinically manage drug-drug interactions that may occur in practice.

Definitions

  • Drug Interaction: The phenomenon of two or more drugs interacting in such a manner that the effectiveness or toxicity of one or more drugs is altered (frequency varies ~10%).
  • Precipitant drug: The drug causing the altered action on another drug.
  • Object drug: The drug whose action is being altered by the interaction.

Pharmacokinetics and Pharmacodynamics

  • Pharmacokinetics (What the body does to a drug):
    • Absorption
    • Distribution
    • Metabolism
    • Excretion
  • Pharmacodynamics (How the body reacts to a drug):
    • Drug concentrations at the site of action and effect
    • Effects of receptor binding, post-receptor effects

Mechanisms of Drug Interactions

  • Synergistic
  • Additive
  • Antagonistic
  • Decreased drug absorption (GI)
  • Protein-binding displacement
  • Enzyme induction
  • Enzyme inhibition
  • Modified drug excretion

Case 1

  • Mr. GS, 59yr male, A.Fib, Diabetes-type 2 (diet controlled) is looking for something to treat his occasional heartburn (1-2x/month).
  • Medications: digoxin 0.125mg po daily, warfarin 5mg po daily (last INR 2.4), ciprofloxacin 500mg po bid + clindamycin 450mg po qid for a resolving diabetic foot infection.
  • Options:
    • A. Mg/Al combo? Maalox? Diovol?
    • B. Alginic acid (Gaviscon)?
    • C. Ca based product (Tums)?
    • D. H2Blocker (Ranitidine or Famotidine)?
    • E. PPI (OTC omeprazole)?
  • Which option(s) could result in adverse effects due to a drug interaction?

Approach to a potential Drug Interaction

  • Complete Medication History (Incl. recent stopped meds)
  • Determine Mechanism of Interaction (Utilize resources)
  • Determine Clinical Significance
    • Theoretical vs. Clinical effect Likely occurrence? Significance? Any data/evidence? Will patient likely experience harm?
  • Clinical Intervention
    • Do nothing + monitor?
    • Separate Timing?
    • Stop drug / Avoid (if possible)?
  • Document
    • Drug Level
    • Patient Level
    • Patient + Drug
    • Clinical Action

Recall… oral medication absorption

  • Dissolves (stomach acid) 
  • Drug in solution (ionized/un-ionized molecules) 
  • Absorption from small intestine (un-ionized drug crosses GI wall)

↓Drug Absorption Overview

  • Drug binding
    • -adsorption
    • -chelation/complexes
  • in GI motility
    • -  gastric emptying
    • -  gastric emptying (extent vs. rate of absorption)
  • in GI pH
  • in Intestinal flora
  • Drug metabolism in the intestinal wall
  • Drug Transporters

↓Drug Absorption: Drug Binding

  • Adsorption
  • Chelation/Complexation

↓Drug Absorption: ∆ in GI motility

  •  GI motility
  •  GI motility (extent vs rate of absorption)

↓Drug Absorption: ∆ in GI pH

  • Weak acids in acidic pH are more likely to be in the lipid-soluble form.
  • Weak bases in an acidic pH are more likely to be in an ionized form.

↓Drug Absorption: Intestinal flora

  • enterohepatic circulation
  • cleaving of bonds

↓Drug Absorption: Drug metabolism in the intestinal wall

  • Monoamine oxidase enzyme
  • CYP 3A4
  • Drug Transporters
    • P-gp (efflux pump)
    • OATP (influx pump)

Intestinal Wall Drug Metabolism and Transporters

  • Lumen
  • Intestinal Enterocyte
    • P-gp
    • 3A4
    • OATP
    • MAO
  • Portal vein

Management of ↓ Drug Absorption Interactions

  • Binding interaction
    • Give object drug 2 hours before precipitant drug
  • GI motility interaction
    • Separation of doses not usually effective. May be useful to give after precipitant drug has worn off
  • ∆’es in GI pH
    • Adjust dosing times (antacids  pH transiently). H2 blockers given qHS – give object drug mid-day
  • Intestinal flora
    • Adjustment of dosing times not effective (∆ in gut flora takes time to occur and recover)
  • Intestinal wall metabolism and drug transport
    • Separate drugs?- poor data, but theoretically may work

Case 1 Discussion

  • The potential DI’s = cipro and mg/al/ca
  • Recall… a “Drug Interaction” is not one of the 7 types of DTP’s! (Hint: what would the PATIENT experience?)

Case 2

  • Mr. SZ has a complex history of seizures. He had been well controlled for several years with phenytoin 300mg po daily. Over the past 6 months, he has had multiple seizures. He is compliant with his medication.
  • His neurologist plans on switching him over to valproic acid by cross-tapering (adding valproic acid, tapering up, while slowly tapering phenytoin down).
  • Mr. SZ has started valproic acid 500mg po daily in addition to his phenytoin 300mg po daily for ~ 7 days. He returns to clinic complaining of drowsiness and dizziness.
  • What is the likely cause of these symptoms?

Protein Binding Displacement

  • Absorption of drug 
  • Distributed through the body 
  • free drug ∆ bound drug (only free drug exerts effect)

Protein Binding Displacement Continued

  • Drugs highly bound are more likely to have a clinically significant effect. E.g. Drug 99% protein bound vs. 60% protein bound
  • Drug with > affinity displaces drug with lesser affinity.
  • Highly protein-bound drugs:
    • Warfarin, amiodarone
    • Methotrexate
    • phenytoin, valproic acid
    • Sulfonamides
    • Ertapenem
    • Fluoxetine, sertraline, nortriptyline

Protein Binding Displacement Bottomline

  • Protein binding displacement interactions rarely result in clinical significance.
  • Watch for in drugs with
    • high protein binding PLUS narrow therapeutic index
  • Management:
    • Monitor levels - Measure free (unbound) object drug

Metabolism

  • Primary Function?
    • Helps the body breakdown substances for easier elimination
  • Phase I
    • CYP P450
    • 3A4, 1A2, 2D6, etc
  • Phase II
  • Enzyme Induction
  • Enzyme Inhibition
  • Concepts: Substrate, Inducer, Inhibitor

Enzyme Induction

  • Involves CYP 450 system (many enzymes) - 3A4 is “inducible”
  • Time frame – slow onset/offset
  • Dose-related

CYP 3A4 Inducers

  • Anticonvulsants
    • Carbamazepine, phenytoin, phenobarbital
  • Rifampin
  • St. John’s Wort
  • Dexamethasone
  • Tobacco smoke
  • Chronic alcohol consumption
  • Etc.

Enzyme Inhibition

  • Involves CYP 450 system
  • Competitive inhibition of object drug isoenzyme
  • Involves 1A2, 2C9, 2D6, 2E1, 3A4 etc!
  • Time frame – quick onset/offset
  • Dose related

CYP 3A4 Inhibitors

  • Macrolides
    • Erythromycin
    • Clarithromycin
  • Calcium Antagonists
    • Verapamil, diltiazem
  • Older quinolones
    • cipro
  • Antifungals
    • Itraconazole
    • ketoconazole
  • Amiodarone
  • Antiretrovirals
    • Indinavir, nelfinavir, saquinavir etc.

Common CYP 3A4 Substrates

  • Statins (some)
    • Atorvastatin, lovastatin, simvastatin
  • DOACs (some)
    • Apixaban, Rivaroxaban
  • Colchicine
  • Estradiol, oral contraceptives
  • Methadone, hydrocodone, fentanyl, oxycodone
  • Sertraline, paroxetine
  • Risperidone, quetiapine
  • Tacrolimus
  • Sildenafil, tadalafil
  • Verapamil
  • Warfarin

CYP 1A2 Substrates, Inhibitors, and Inducers

  • Substrates: Caffeine, Clopidogrel, Estradiol, Methadone, Theophylline, Warfarin
  • Inhibitors: Ciprofloxacin, Fluvoxamine, Fluconazole, Amiodarone, Verapamil
  • Inducers: Carbamazepine, Phenobarbital, Rifampin, Smoking

Case 3

  • 72-year-old female with CAD, DM2, HTN
  • Develops symptoms of UTI
  • Rx’d Septra
  • 2 days later:
    • Confused upon awakening
    • Generalized seizure

Case 3 Continued

  • Blood glucose = 0.9mmol/L
  • Patient takes glyburide 10 mg po bid
  • Metabolized by CYP 2C9
  • CYP 2C9 inhibited by SMX/TMP

CYP 2C9 Substrates, Inhibitors, and Inducers

  • Substrates: Sulfonylureas, Warfarin, Fluvastatin, Methadone, Warfarin
  • Inhibitors: SMX/TMP, Metronidazole, Fluvoxamine, Fluoxetine, Fluconazole, Amiodarone
  • Inducers: Carbamazepine, phenobarbital, phenytoin, Rifampin, St. John’s Wort, Phenobarbital, phenytoin

CYP 2D6 Substrates and Inhibitors

  • Substrates: Codeine, Carvedilol, Metoprolol, Haloperidol, Risperidone
  • Inhibitors: Amiodarone, SSRI’s, Haloperidol, Bupropion, Ritonavir

Modified Drug Excretion

  • Renal excretion:
    • Glomerular filtration – non-protein-bound drugs
    • Active tubular secretion – acidic and basic drugs
    • Passive tubular reabsorption - non-ionized drugs

Modified Drug Excretion - Clinically significant interactions are more likely to occur if:

  1. Drug is excreted unchanged e.g. lithium
  2. Narrow therapeutic window e.g. digoxin, cyclosporine, theophylline etc.
  3. High plasma concentration of drug – precipitant drug pushes levels into toxic range
    • Bottomline: Overall, this mechanism is an uncommon cause of clinically significant drug interactions.

Drug Transporters

  • P-glycoprotein (P-gp)
  • Organic Anion Transporting Polypeptide (OATP)

Case 4

  • 92-year-old female with A. Fib, penicillin allergy
  • Independent, lives alone
  • digoxin 0.125mg po daily
  • Arrives at the Emergency feeling unwell x 2 days
  • Recent Rx for Clarithromycin (Biaxin) 500mg po bid x 7days for cellulitis

P-Glycoprotein (P-gp)

  • Transporter protein in the brush border of the intestinal wall
  • Pumps “out” toxins to ensure saturation of intestinal wall enzymes (eg. CYP 3A4) does not occur

P-Glycoprotein Substrates, Inhibitors, and Inducers

  • Substrates: Digoxin, Loperamide, Diltiazem, Midazolam, Cyclosporine, Chemo (various), Cyclosporine, Colchicine
  • Inhibitors: Macrolides, Amiodarone, Antifungals, Quinidine, Protease inhibitors, Verapamil, Ritonavir
  • Inducers: Rifampin, Dexamethasone, St. John’s Wort

Organic Anion Transporting Polypeptide (OATP)

  • Family of influx transporters expressed in various tissues (intestine, liver, kidney, other)
  • Pumps drugs “into” a cell – often to be excreted
  • Though effect will vary depending on location of OATP.
  • Inhibiting OAPT in the liver or kidney will increase drug level (most common)
  • (Inhibiting OAPT in the GI tract, will decrease drug level)

OATP Substrates and Inhibitors

  • Substrates: Statins, Angiotensin Receptor Blockers, Ciprofloxacin, Erythromycin, Montelukast, Fexofenadine
  • Inhibitors: Clarithromycin, Cyclosporine, Erythromycin, Gemfibrozil, Grapefruit, Ketoconazole, Rifampin, Protease Inhibitors

Grapefruit Juice

  • Inhibits CYP 3A4 in the intestinal wall (not hepatic) thereby ’ing 1st pass metabolism
  • Result = higher bioavailability,  plasma concentrations
  • Drugs with steep conc/response curves, narrow therapeutic index, if [plasma] doubles.

CYP 3A4 Substrates and bioavailability

  • Very low (
  • Low (10%-30%): Atorvastatin, felodipine
  • Intermediate (30% to 70%): Amio, CBZ, CyA, diazepam, diltiazem, nifedipine Silendafil, triazolam
  • High (>70%): Alprazolam, amlodipine, dexamethasone, quetiapine

Conclusions: Clinically Significant Drug Interactions More Likely When

  1. Drugs with narrow therapeutic range
  2. Drugs with high plasma drug concentrations
  3. Drugs undergoing extensive 1st pass metabolism
  4. Drugs highly protein bound

Case 5

  • BP is a 27-year-old female with a history of Bipolar affective disorder. She is brought to the emergency department after falling off her bicycle following a collision with a car.
  • The physician asks you to dispense meperidine 150mg IM to the nurse for administration to BP for her pain.
  • Allergies: Codeine
  • Current medications:
    • Phenelzine 15mg po daily
    • Vitamin C 500mg po daily
    • Naproxen 225mg po daily prn
    • TriCyclen 28 1 tab po daily
  • Is there a drug interaction? If so, what is the DTP?

Pharmacodynamic Drug Interactions

  1. Synergistic
    • SSRI’s and St John’s Wort  Serotonin Syndrome
  2. Additive
    • K+ sparing diuretics and ACEI’s  Elevated K levels
    • ACEI’s and B-blockers  enhanced BP lowering
  3. Antagonistic
    • Morphine and naloxone  reversal of pain relief
    • Vitamin K and Warfarin  reversal of inability to clot quickly
  • Time frame – rapid onset/offset
  • Easy to detect

Case 5 Discussion

  • The relevant meds are Phenelzine (MAOI) and Meperidine
  • Pharmacodynamic Interaction
  • Meperidine is contraindicated with MAOIs due to risk of serotonin syndrome.

Common Pharmacodynamic Interactions

  • Cumulative anticholinergic load
  • Bleed risk

Miscellaneous concepts

  • Prodrugs
  • QT prolongation

Case 6

  • SN is a 72-year-old male who recently (4 days ago) experienced a STEMI. He underwent PCI and had 2 stents inserted.
  • Allergies: none
  • Medications on discharge from hospital:
    • Clopidogrel 75mg po daily
    • EC ASA 81mg po daily
    • Omeprazole 40mg po daily
    • Ramipril 5mg po daily
    • Metoprolol 25mg po bid
    • Atorvastatin 40mg po qhs
  • Is there a drug interaction here? If so, what is the DTP?

Prodrugs

  • Drugs that need to be metabolized to become activated
  • Thus, effects on metabolism will either increase or decrease the amount of ‘activated’ drug
  • E.g. Clopidogrel requires metabolization via CYP450 2C19 to an active metabolite that is actually responsible for all its efficacy.

Case 6 - Discussion

  • The relevant meds are Clopidogrel and Omeprazole.
  • Omeprazole inhibits CYP2C19, the enzyme responsible for activating clopidogrel. Using them together may reduce the effectiveness of clopidogrel.

Case 7

  • AR is a 75-year-old female who was diagnosed at a local walk-in clinic with pneumonia. She presents to you a new prescription for Levofloxacin 750mg po daily x5days. Baseline QT interval is 453 msec.
  • Allergies: None
  • Current medications:
    • EC ASA 81mg po daily
    • Amiodarone 200mg po bid
    • Atorvastatin 20mg po qhs
    • Furosemide 40mg po QAM
    • Metoprolol 25mg po bid
    • Ramipril 5mg po daily
  • Is there a drug interaction? If so, what is the DTP?

Drug-induced QT prolongation

  • Drug-associated:
    • Antiarrhythmic agents
      • Particularly Class 1A (Quinidine, procainamide)
      • Class 3 (Sotalol > amiodarone)
    • Antidepressants (TCAs)
    • Antipsychotics (Haloperidol, thioridazine, quetiapine)
    • Antimicrobials (Quinolones, macrolides)
    • Antifungals (ketoconazole)
    • Prokinetic agents (domperidone)
    • Methadone
    • Tamoxifen
  • Non-drug risk factors
    • Female
    • Advanced age
    • Hypokalemia or hypomagnesemia (can be caused by drugs too)
    • Heart failure
    • Bradycardia
    • Ischemia
    • Congenital
  • QT prolongation can lead to torsade de pointes (TdP)
  • Considered prolonged if QTc Interval is > 450 msec (men); >460 msec (women)
  • Interactions can be Pharmacokinetic or Pharmacodynamic to increase QT

Drug-induced QT prolongation - How to manage?

  • Although the risk for a single agent may be very low
  • Risk increases with PK interactions which increase an object drug into supratherapeutic levels;
  • Risk increases significantly with PD interactions with multiple agents each prolonging QT
  • Avoid combinations (if possible)
  • Select drugs less associated with QT prolongation
  • Risk vs. Benefit
  • Stop medication if prolonged QTc (>450 msec (men), >460 msec (women)) or if prolonged by more than 60 msec from baseline
  • (* AHA/ACCF guidelines suggest stopping if QTc >500ms (in hospital setting))
  • ECG at baseline + repeat when the drug is at steady-state

Case 7 - Discussion

  • Levofloxacin and Amiodarone both increase QT interval.
  • The patient's baseline QT is already prolonged, and adding levofloxacin increases the risk of torsades de pointes (TdP).

Case 8

  • BR is a 66-year-old female who presents to your clinic with presumed low-risk, outpatient treatable CAP. They receive a prescription for clarithromycin 500mg po bid x7 days.
  • PMHx
    • generally healthy except had an unprovoked DVT – discovered last month
  • Allergies: beta-lactams and ciprofloxacin.
  • Medications:
    • Edoxaban 60mg po daily (started ~ 1 month ago)
    • Multivitamin 1 tablet po daily
  • Assuming the antibiotic prescription was appropriate, what would be the best course of action?

DOAC Drug Interaction Mechanisms

  • Dabigatran:
    • CYP450: -
    • P-gp: Substrate -(weak inhibitor)
    • OATP: -
  • Rivaroxaban:
    • CYP450: 3A4 (50% metabolized) (3A5, 2J2)
    • P-gp: Substrate
    • OATP: Substrate of OAT3
  • Apixaban:
    • CYP450: 3A4 (20-25% metabolized)
    • P-gp: Substrate
    • OATP: -
  • Edoxaban:
    • CYP450: 3A4 (minor – 4%)
    • P-gp: Substrate - (Weak inhibitor)
    • OATP: -

DOAC Enzyme Inhibitor Interaction Management

  • Dabigatran:
    • P-gp Inhibitor (macrolides, amiodarone, ketoconazole, quinidine, cyclosporine, verapamil, ritonavir): ↓ dose or avoid
  • Rivaroxaban:
    • STRONG 3A4 inhibitor + P-gp inhibitor (itraconazole, ketoconazole, ritonavir): Avoid
  • Apixaban:
    • STRONG 3A4 inhibitor + P-gp inhibitor (itraconazole, ketoconazole, ritonavir): ↓ dose or avoid
  • Edoxaban:
    • P-gp Inhibitor (macrolides, amiodarone, ketoconazole, quinidine, cyclosporine, verapamil, ritonavir)
      • Afib – continue dose
      • VTE Tx - ↓ dose

Case 8 - Discussion

  • Edoxaban is a substrate of P-gp, and Clarithromycin is a P-gp inhibitor.
  • Coadministration can increase Edoxaban levels, increasing bleeding risk.
  • For VTE treatment, reduce the dose to edoxaban 30mg po daily while on clarithromycin

Drug Interaction Resources

  • Hansten + Horn
    • Drug Interactions
    • Top 100 Drug Interactions – A guide to Patient Management
  • Stockley’s Drug Interactions
  • Electronic:
    • MICROMEDEX
    • Lexi-Comp
    • eCPS (powered by Lexi-comp)
  • CPOE – most will utilize a drug database with interaction checker (e.g. FDB)

Other Drug Interaction Resources

  • HIV
    • Toronto General HIV (Immunodeficiency)Clinic Handbook/Charts (www.hivclinic.ca)
    • UCSF database of HIV Interactions (arv.ucsf.edu)
    • University of Liverpool (www.hiv-druginteractions.org)
  • Indiana University School of Medicine (Dr. David Flockhart) (www.drug-interactions.com)
  • QT prolongation interactions (www.crediblemeds.org)
  • For patients: FDA – Drugs – Resources for you Series (http://www.fda.gov/Drugs/ResourcesForYou/ucm163354.htm)
  • Handbook on Drug and Nutrient Interactions