title: Ritonavir increases loperamide plasma concentrations without evidence for P-glycoprotein involvement.
abstract: BACKGROUND
  The antidiarrheal drug loperamide is frequently used to treat ritonavir-associated diarrhea in patients with human immunodeficiency virus. The absence of marked central opioid effects has been attributed to its low bioavailability and its poor penetration of the blood-brain barrier, both of which might be altered by ritonavir, a potent P-glycoprotein and cytochrome P4503A inhibitor.
  
  
  METHODS
  A 16-mg dose of loperamide was administered to 12 healthy male and female volunteers together with either 600 mg of ritonavir or placebo. Detailed pharmacokinetics of loperamide and its metabolites were determined over 72 hours. Central opioid effects were measured by evaluation of pupil diameter, cold pressor test, and transcutaneous PCO2 and PO2.
  
  
  RESULTS
  Ritonavir caused a major pharmacokinetic interaction, increasing the area under the concentration-time curve of loperamide from 104 +/- 60 h x pmol/ml after placebo to 276 +/- 68 h. pmol/ml and delayed formation of the major metabolite desmethylloperamide (time to reach maximum concentration after drug administration [t(max)], 7.1 +/- 2.6 hours versus 19.6 +/- 9.1 hours). The urinary metabolic ratio of loperamide increased 3 times whereas the total molar amount of loperamide and metabolites excreted in urine remained unchanged. No central pharmacodynamic effects were observed after coadministration of loperamide with either ritonavir or placebo.
  
  
  CONCLUSIONS
  This study demonstrates a major metabolic interaction probably by cytochrome P4503A4 with no evidence of P-glycoprotein involvement. This might explain the lack of central effects after ritonavir.
authors.affiliation: Department of Internal Medicine VI, Clinical Pharmacology and Pharmacoepidemiology, University Hospital, and Institute of Legal Medicine and Traffic Medicine, Heidelberg, Germany.
authors.forename: Y
authors.initials: Y
authors.lastname: Tayrouz
authors.forename: B
authors.initials: B
authors.lastname: Ganssmann
authors.forename: R
authors.initials: R
authors.lastname: Ding
authors.forename: A
authors.initials: A
authors.lastname: Klingmann
authors.forename: R
authors.initials: R
authors.lastname: Aderjan
authors.forename: J
authors.initials: J
authors.lastname: Burhenne
authors.forename: W E
authors.initials: WE
authors.lastname: Haefeli
authors.forename: G
authors.initials: G
authors.lastname: Mikus
mesh_terms: D020168:ATP Binding Cassette Transporter, Subfamily B, Member 1 / Q000502:physiology*; D000328:Adult; D000930:Antidiarrheals / Q000097:blood*; D019540:Area Under Curve; D001189:Aryl Hydrocarbon Hydroxylases; D018592:Cross-Over Studies; D051544:Cytochrome P-450 CYP3A; D065607:Cytochrome P-450 Enzyme Inhibitors; D003577:Cytochrome P-450 Enzyme System / Q000502:physiology; D004311:Double-Blind Method; D005260:Female; D017320:HIV Protease Inhibitors / Q000494:pharmacology*; D006801:Humans; D008139:Loperamide / Q000097:blood*; D008297:Male; D008875:Middle Aged; D010089:Oxidoreductases, N-Demethylating / Q000037:antagonists & inhibitors / Q000502:physiology; D019438:Ritonavir / Q000494:pharmacology*
chemical_list: D020168:ATP Binding Cassette Transporter, Subfamily B, Member 1; D000930:Antidiarrheals; D065607:Cytochrome P-450 Enzyme Inhibitors; D017320:HIV Protease Inhibitors; D008139:Loperamide; D003577:Cytochrome P-450 Enzyme System; D001189:Aryl Hydrocarbon Hydroxylases; D051544:Cytochrome P-450 CYP3A; D010089:Oxidoreductases, N-Demethylating; D019438:Ritonavir