Drug interaction between mycophenolate mofetil and rifampin: possible induction of uridine diphosphate-glucuronosyltransferase.
The tuberculostatic compound rifampin (INN, rifampicin) induces the expression of a number of drug metabolism-related genes involved in multidrug resistance (P-glycoprotein and multidrug resistance proteins 1 and 2), cytochromes (cytochrome P450 [CYP] 3A4), uridine diphosphate-glucuronosyltransferases, monoamine oxidases, and glutathione S -transferases. Drugs that depend on these enzymes for their metabolism are prone to drug interactions when coadministered with rifampin. A novel, clinically relevant drug interaction is described between rifampin and mycophenolate mofetil (MMF), a cornerstone immunosuppressive molecule used in solid organ transplantation. Long-term rifampin therapy caused a more than twofold reduction in dose-corrected mycophenolic acid (MPA) exposure (dose-interval area under the concentration curve from 0 to 12 hours [AUC 0-12]) when administered simultaneously in a heart-lung transplant recipient, whereas subsequent withdrawal of rifampin resulted in reversal of these changes after 2 weeks of washout (dose-corrected AUC 0-12 after rifampin withdrawal, 19.7 mg.h.L-1.g -1 versus 6.13 mg.h.L-1.g-1 before rifampin withdrawal [221% change]; dose-uncorrected AUC 0-12 after rifampin withdrawal, 29.6 mg.h/L [daily MMF dose, 3 g] versus 18.4 mg.h/L [daily MMF dose, 6 g] during rifampin administration [60.8% change]). Failure to recognize this drug interaction could potentially lead to MPA underexposure and loss of clinical efficacy. The effect of rifampin on MPA metabolism can, at least in part, be explained by simultaneous induction of renal, hepatic, and gastrointestinal uridine diphosphate-glucuronosyltransferases and organic anion transporters with subsequent functional inhibition of enterohepatic recirculation of MPA.
Department of Nephrology and Renal Transplantation, University Hospitals Leuven, B-3000 Leuven, Belgium. Dirk.Kuypers@uz.kuleuven.ac.be
Dirk R J
DR
Kuypers
Geert
G
Verleden
Maarten
M
Naesens
Yves
Y
Vanrenterghem
D019540:Area Under Curve; D002908:Chronic Disease; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D004347:Drug Interactions; D004359:Drug Therapy, Combination; D004764:Enterohepatic Circulation / Q000187:drug effects / Q000502:physiology; D014453:Glucuronosyltransferase / Q000096:biosynthesis*; D016041:Heart-Lung Transplantation; D006646:Histiocytosis, Langerhans-Cell / Q000150:complications / Q000175:diagnosis; D006801:Humans; D006976:Hypertension, Pulmonary / Q000150:complications / Q000175:diagnosis; D008297:Male; D008657:Metabolic Clearance Rate / Q000187:drug effects; D008875:Middle Aged; D009173:Mycophenolic Acid / Q000031:analogs & derivatives* / Q000097:blood / Q000494:pharmacology / Q000627:therapeutic use*; D010601:Pharmacology, Clinical / Q000193:education / Q000379:methods; D012131:Respiratory Insufficiency / Q000150:complications / Q000175:diagnosis; D012293:Rifampin / Q000494:pharmacology / Q000627:therapeutic use*; D016559:Tacrolimus / Q000097:blood / Q000627:therapeutic use; D013997:Time Factors; D014530:Uridine Diphosphate / Q000096:biosynthesis*; D028761:Withholding Treatment
D014530:Uridine Diphosphate; D014453:Glucuronosyltransferase; D009173:Mycophenolic Acid; D012293:Rifampin; D016559:Tacrolimus