Effects of grapefruit juice on the pharmacokinetics of the enantiomers of methadone.
OBJECTIVE
Cytochrome P450 (CYP) 3A4 is the main CYP isozyme involved in methadone metabolism. We investigated the influence of grapefruit juice, which contains inhibitors of intestinal CYP3A, on the steady-state pharmacokinetics of methadone.


METHODS
For 5 days, 8 patients undergoing methadone maintenance treatment received 200 mL water or grapefruit juice 30 minutes before and again together with their daily dose of methadone. Blood sampling for R-, S-, and R,S-methadone plasma determination was performed over a 24-hour period. CYP3A activity was determined by measuring the plasma 1'-hydroxymidazolam/midazolam ratio.


RESULTS
A decrease in the midazolam ratio was measured in all patients after grapefruit juice (mean +/- SD before grapefruit juice, 9.3 +/- 5.9; mean +/- SD after grapefruit juice, 3.9 +/- 1.2; P <.05). Grapefruit juice led to a mean 17% increase in the area under the curve extrapolated to 24 hours for both enantiomers of methadone (range, 3% to 29% [P <.005]; range, -4% to 37% [P <.05]; and range, 1% to 32% [P <.01]; for R-, S-, and R,S-methadone, respectively). A similar increase in peak level and decrease in apparent clearance were measured with grapefruit juice, whereas time to peak level, terminal half-life, and apparent volume during the terminal phase of R-, S-, and R,S-methadone were not affected by grapefruit juice. No symptom of overmedication was either detected by the clinical staff or reported by the patients.


CONCLUSIONS
Grapefruit juice administration is associated with a modest increase in methadone bioavailability, which is not expected to endanger patients. However, it cannot be excluded that a much stronger effect may occur in some patients, and thus grapefruit juice intake is not recommended during methadone maintenance treatment, in particular in patients initiating such a treatment.
Benmebarek
Messaoud
M
Service of Medicine and Penitentiary Psychiatry, University Department of Adult Psychiatry, Lausanne, Switzerland.
Devaud
Corinne
C
Gex-Fabry
Marianne
M
Powell Golay
Kerry
K
Brogli
Christian
C
Baumann
Pierre
P
Gravier
Bruno
B
Eap
Chin B
CB
D000328:Adult; D019540:Area Under Curve; D001628:Beverages; D032083:Citrus paradisi; D051544:Cytochrome P-450 CYP3A; D003577:Cytochrome P-450 Enzyme System / Q000502:physiology; D005260:Female; D006801:Humans; D008297:Male; D008657:Metabolic Clearance Rate; D008691:Methadone / Q000493:pharmacokinetics*; D008875:Middle Aged; D013237:Stereoisomerism
D003577:Cytochrome P-450 Enzyme System; C104464:CYP3A protein, human; D051544:Cytochrome P-450 CYP3A; D008691:Methadone