title: Repeated ingestion of grapefruit juice does not alter clozapine's steady-state plasma levels, effectiveness, and tolerability.
abstract: BACKGROUND
  Grapefruit juice can inhibit the gastrointestinal activity of cytochrome P450 (CYP) 3A4, while its effect on CYP1A2 remains controversial. Several grapefruit juice bioflavonoids also modulate the activity of the drug transporter P-glycoprotein in the gut and in the blood-brain barrier. Both CYP1A2 and CYP3A4 are involved in clozapine metabolism. This study investigated the effects of repeated ingestion of grapefruit juice on multiple-dose pharmacokinetics and pharmacodynamics of clozapine in schizophrenic patients.
  
  
  METHODS
  Clozapine therapy was initiated for fifteen treatment-resistant schizophrenic inpatients (DSM-IV criteria). The doses were individually titrated from day -35 to day -15 and then kept unchanged from day -14 to day 49. Regular-strength grapefruit juice (250 mL) was coadministered b.i.d. with each clozapine dose from day 15 to day 28. Plasma levels of clozapine and its main metabolites (norclozapine and clozapine N-oxide) were obtained, and clinical efficacy and safety assessments were completed prior to juice administration (days 0, 7, and 14), during the coadministration (days 17, 21, and 28), and after cessation of the juice (days 35, 42, and 49).
  
  
  RESULTS
  After reaching steady states, plasma concentrations of clozapine and its metabolites and Positive and Negative Syndrome Scale scores were not significantly altered by the effect of grapefruit juice ingestion. The Clinical Global Impressions scale scores, Calgary Depression Scale scores, and side effect profiles (by the Extrapyramidal Symptom Rating Scale, the UKU Side Effect Rating Scale, and thorough examinations including electrocardiography and electroencephalography) also remained constant during the study.
  
  
  CONCLUSIONS
  Consumption of regular-strength grapefruit juice, 250 mL b.i.d., for 14 days did not significantly impact clozapine metabolism, clinical efficacy, or tolerability. One reason is that enzymes other than CYP3A4 also mediate clozapine disposition. Also, grapefruit juice inhibits CYP3A4 in the gut, but not in the liver. The preliminary results also suggest that clozapine is unlikely to be a P-glycoprotein substrate. Further rigorous studies are necessary to reconfirm these findings.
authors.affiliation: Department of Psychiatry, Tzu-Chi General Hospital and Tzu-Chi University, Taipei, Taiwan.
authors.forename: H Y
authors.initials: HY
authors.lastname: Lane
authors.forename: M W
authors.initials: MW
authors.lastname: Jann
authors.forename: Y C
authors.initials: YC
authors.lastname: Chang
authors.forename: C C
authors.initials: CC
authors.lastname: Chiu
authors.forename: M C
authors.initials: MC
authors.lastname: Huang
authors.forename: S H
authors.initials: SH
authors.lastname: Lee
authors.forename: W H
authors.initials: WH
authors.lastname: Chang
mesh_terms: D000328:Adult; D001628:Beverages / Q000009:adverse effects*; D002957:Citrus; D003024:Clozapine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000493:pharmacokinetics* / Q000627:therapeutic use; D005260:Female; D018565:Food-Drug Interactions; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011569:Psychiatric Status Rating Scales; D012559:Schizophrenia / Q000097:blood* / Q000188:drug therapy
chemical_list: C058272:norclozapine; D003024:Clozapine; C079149:clozapine N-oxide