title: Active tamoxifen metabolite plasma concentrations after coadministration of tamoxifen and the selective serotonin reuptake inhibitor paroxetine.
abstract: BACKGROUND
  Tamoxifen, a selective estrogen receptor modulator (SERM), is converted to 4-hydroxy-tamoxifen and other active metabolites by cytochrome P450 (CYP) enzymes. Selective serotonin reuptake inhibitors (SSRIs), which are often prescribed to alleviate tamoxifen-associated hot flashes, can inhibit CYPs. In a prospective clinical trial, we tested the effects of coadministration of tamoxifen and the SSRI paroxetine, an inhibitor of CYP2D6, on tamoxifen metabolism.
  
  
  METHODS
  Tamoxifen and its metabolites were measured in the plasma of 12 women of known CYP2D6 genotype with breast cancer who were taking adjuvant tamoxifen before and after 4 weeks of coadministered paroxetine. We assessed the inhibitory activity of pure tamoxifen metabolites in an estradiol-stimulated MCF7 cell proliferation assay. To determine which CYP isoforms were involved in the metabolism of tamoxifen to specific metabolites, we used CYP isoform-specific inhibitors. All statistical tests were two-sided.
  
  
  RESULTS
  We separated, purified, and identified the metabolite 4-hydroxy-N-desmethyl-tamoxifen, which we named endoxifen. Plasma concentrations of endoxifen statistically significantly decreased from a mean of 12.4 ng/mL before paroxetine coadministration to 5.5 ng/mL afterward (difference = 6.9 ng/mL, 95% confidence interval [CI] = 2.7 to 11.2 ng/mL) (P =.004). Endoxifen concentrations decreased by 64% (95% CI = 39% to 89%) in women with a wild-type CYP2D6 genotype but by only 24% (95% CI = 23% to 71%) in women with a variant CYP2D6 genotype (P =.03). Endoxifen and 4-hydroxy-tamoxifen inhibited estradiol-stimulated MCF7 cell proliferation with equal potency. In vitro, troleandomycin, an inhibitor of CYP3A4, inhibited the demethylation of tamoxifen to N-desmethyl-tamoxifen by 78% (95% CI = 65% to 91%), and quinidine, an inhibitor of CYP2D6, reduced the subsequent hydroxylation of N-desmethyl-tamoxifen to endoxifen by 79% (95% CI = 50% to 108%).
  
  
  CONCLUSIONS
  Endoxifen is an active tamoxifen metabolite that is generated via CYP3A4-mediated N-demethylation and CYP2D6-mediated hydroxylation. Coadministration of paroxetine decreased the plasma concentration of endoxifen. Our data suggest that CYP2D6 genotype and drug interactions should be considered in women treated with tamoxifen.
authors.affiliation: The Breast Cancer Program, Department of Medicine, Lombardi Cancer Center, Georgetown University Medical Center, Washington, DC, USA.
authors.forename: Vered
authors.initials: V
authors.lastname: Stearns
authors.forename: Michael D
authors.initials: MD
authors.lastname: Johnson
authors.forename: James M
authors.initials: JM
authors.lastname: Rae
authors.forename: Alan
authors.initials: A
authors.lastname: Morocho
authors.forename: Antonella
authors.initials: A
authors.lastname: Novielli
authors.forename: Pankaj
authors.initials: P
authors.lastname: Bhargava
authors.forename: Daniel F
authors.initials: DF
authors.lastname: Hayes
authors.forename: Zeruesenay
authors.initials: Z
authors.lastname: Desta
authors.forename: David A
authors.initials: DA
authors.lastname: Flockhart
mesh_terms: D000328:Adult; D000368:Aged; D018931:Antineoplastic Agents, Hormonal / Q000008:administration & dosage / Q000097:blood / Q000493:pharmacokinetics*; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000097:blood / Q000493:pharmacokinetics* / Q000627:therapeutic use; D001943:Breast Neoplasms / Q000097:blood* / Q000188:drug therapy* / Q000201:enzymology; D017024:Chemotherapy, Adjuvant; D065690:Cytochrome P-450 CYP2D6 Inhibitors; D051544:Cytochrome P-450 CYP3A; D065607:Cytochrome P-450 Enzyme Inhibitors; D004791:Enzyme Inhibitors / Q000494:pharmacology; D005260:Female; D006801:Humans; D008862:Microsomes, Liver / Q000378:metabolism; D008875:Middle Aged; D017374:Paroxetine / Q000008:administration & dosage / Q000097:blood / Q000493:pharmacokinetics*; D011446:Prospective Studies; D020845:Selective Estrogen Receptor Modulators / Q000008:administration & dosage / Q000097:blood / Q000493:pharmacokinetics*; D017367:Selective Serotonin Reuptake Inhibitors / Q000008:administration & dosage / Q000097:blood / Q000493:pharmacokinetics*; D013629:Tamoxifen / Q000008:administration & dosage / Q000031:analogs & derivatives* / Q000097:blood / Q000493:pharmacokinetics*; D016896:Treatment Outcome
chemical_list: D018931:Antineoplastic Agents, Hormonal; D065690:Cytochrome P-450 CYP2D6 Inhibitors; D051544:Cytochrome P-450 CYP3A; D065607:Cytochrome P-450 Enzyme Inhibitors; D004791:Enzyme Inhibitors; D017374:Paroxetine; D020845:Selective Estrogen Receptor Modulators; D017367:Selective Serotonin Reuptake Inhibitors; D013629:Tamoxifen; C016601:afimoxifene; C104464:CYP3A protein, human; C510163:CYP3A4 protein, human