title: Effect of hepatic impairment on the pharmacokinetics of atomoxetine and its metabolites.
abstract: OBJECTIVE
  Atomoxetine is a treatment for attention-deficit/hyperactivity disorder and is primarily eliminated via cytochrome P4502D6 (CYP2D6). The pharmacokinetics of atomoxetine and its primary metabolites were investigated in 10 adults with hepatic impairment (6 moderate, 4 severe) and 10 age- and sex-matched control subjects, all being genotyped as CYP2D6 extensive metabolizers.
  
  
  METHODS
  A single oral 20-mg dose of atomoxetine was given. Multiple blood samples were collected for 48 hours in healthy subjects and for 120 hours in patients. Urine was collected up to 24 hours. Before atomoxetine administration (10-20 days), sorbitol clearance and debrisoquin (INN, debrisoquine) metabolic ratio were determined as markers of hepatic blood flow and CYP2D6 activity, respectively.
  
  
  RESULTS
  The systemic clearance of atomoxetine was significantly reduced in those with hepatic impairment compared with controls, thereby resulting in increased exposure (area under the concentration-time curve from time 0 to infinity, 1.58 versus 0.85 microg. h(-1). mL(-1); P =.035) but no change in maximum concentration. Mean 4-hydroxyatomoxetine area under the concentration-time curve from time 0 to time t and maximum concentration were increased approximately 7-fold and 2-fold, respectively (P =.0001 and P =.0056, respectively). For the glucuronide conjugate of 4-hydroxyatomoxetine, the mean half-life was longer and the mean area under the concentration-time curve from time 0 to infinity and the maximum concentration were lower (P =.0028, P =.003, and P =.0001, respectively). The sorbitol clearance was lower and the debrisoquin metabolic ratio was higher, reflecting reduced hepatic blood flow and decreased CYP2D6 activity, respectively. Decreased atomoxetine clearance in patients with hepatic impairment was clearly correlated with decreased CYP2D6 activity and decreased hepatic blood flow. Mean atomoxetine plasma protein binding was lower in patients with hepatic impairment compared with controls (96.5% versus 98.7%, P =.0008). Atomoxetine was well tolerated in the 2 populations.
  
  
  CONCLUSIONS
  For patients with attention-deficit/hyperactivity disorder who have hepatic impairment, dosage adjustment is recommended. Initial target doses should be reduced to 25% and 50% of the normal dose for patients with severe and moderate hepatic impairment, respectively.
authors.affiliation: Department of Clinical Pharmacology, Lilly Research Laboratories, Lilly Development Centre SA, Parc Scientifique de Louvain-La-Neuve, Rue Granbonpré 11, 1348 Mont-Saint-Guibert, France. chalon_stephane_a@lilly.com
authors.forename: Stephan A
authors.initials: SA
authors.lastname: Chalon
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Desager
authors.forename: Karl A
authors.initials: KA
authors.lastname: Desante
authors.forename: Reginald F
authors.initials: RF
authors.lastname: Frye
authors.forename: Jennifer
authors.initials: J
authors.lastname: Witcher
authors.forename: Amanda J
authors.initials: AJ
authors.lastname: Long
authors.forename: John-Michael
authors.initials: JM
authors.lastname: Sauer
authors.forename: Jean-Luc
authors.initials: JL
authors.lastname: Golnez
authors.forename: Brian P
authors.initials: BP
authors.lastname: Smith
authors.forename: Holly R
authors.initials: HR
authors.lastname: Thomasson
authors.forename: Yves
authors.initials: Y
authors.lastname: Horsmans
mesh_terms: D000284:Administration, Oral; D000328:Adult; D000928:Antidepressive Agents / Q000008:administration & dosage / Q000097:blood / Q000493:pharmacokinetics* / Q000652:urine; D019540:Area Under Curve; D000069445:Atomoxetine Hydrochloride; D001289:Attention Deficit Disorder with Hyperactivity / Q000188:drug therapy; D016022:Case-Control Studies; D019389:Cytochrome P-450 CYP2D6 / Q000235:genetics / Q000378:metabolism; D003647:Debrisoquin / Q000378:metabolism / Q000652:urine; D005260:Female; D006801:Humans; D008103:Liver Cirrhosis / Q000378:metabolism* / Q000473:pathology; D008297:Male; D008657:Metabolic Clearance Rate; D008875:Middle Aged; D011437:Propylamines / Q000008:administration & dosage / Q000097:blood / Q000493:pharmacokinetics* / Q000652:urine; D012720:Severity of Illness Index; D013012:Sorbitol / Q000097:blood / Q000378:metabolism
chemical_list: D000928:Antidepressive Agents; D011437:Propylamines; D013012:Sorbitol; D000069445:Atomoxetine Hydrochloride; D019389:Cytochrome P-450 CYP2D6; D003647:Debrisoquin