A COMBINED MODEL FOR PREDICTING CYP3A4 CLINICAL NET DRUG-DRUG INTERACTION, BASED ON CYP3A4 INHIBITION.

M. PHARM DISSERTATION PROTOCOL

SUBMITTED TO THE

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BENGALURU.

By

NASERA SULTANA B. Pharm

UNDER THE GUIDANCE OF

Dr. D.K. SURESH M Pharm, PhD

DEPARTMENT OF PHARMACOLOGYLUQMAN COLLEGE OF PHARMACY, GULBARGA

2012-13

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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

ANNEXURE-II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the Candidate(In block letters) and Address

NASERA SULTANA

H.NO. 17-3-3/1/21A

AZMATH NAGAR,

YAKUTPURA COLONY,

HYDERABAD-500023

2. Name of the Institution LUQMAN COLLEGE OF PHARMACY, GULBARGA – 585 102.

3. Course of Study and Subject MASTER OF PHARMACY IN PHARMACOLOGY.

4. Date of Admission to Course 12/07/2012

5. Title of the Topic A COMBINED MODEL FOR PREDICTING CYP3A4 CLINICAL NET DRUG-DRUG INTERACTION, BASED ON CYP3A4 INHIBITION.

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6. Brief Resume of the intended work

6.1 Need for study:

Drug-drug interactions are possible whenever a person takes two or more medications concurrently.

There are a number of mechanisms by which drugs interact with each other, and most of them can

be divided into two general categories: pharmacokinetic and pharmacodynamic interactions. With

pharmacokinetic drug interactions, one drug affects the absorption, distribution, metabolism, or

excretion of another. When pharmacodynamic drug interactions occur, two drugs have additive or

antagonistic pharmacologic effects. Either type of drug interaction can result in adverse effects in

some individuals.1 When discussing drug interactions, the drug affected by the interaction is called

the “object drug,” and the drug causing the interaction is called the “precipitant drug.”1

Diabetes mellitus (sometimes called "sugar diabetes") is a condition that occurs when the body can't

use glucose (a type of sugar) normally. Glucose is the main source of energy for the body's cells.

The levels of glucose in the blood are controlled by a hormone called insulin, which is made by the

pancreas. Insulin helps glucose enter the cells.2 In diabetes, the pancreas does not make enough

insulin (type 1 diabetes) or the body can't respond normally to the insulin that is made (type 2

diabetes). This causes glucose levels in the blood to rise, leading to symptoms such as increased

urination, extreme thirst, and unexplained weight loss.2

For the purpose of classification, the disease can be classified in the following three groups: Type 1

Diabetes, Type 2 Diabetes and Gestational Diabetes.3

Nearly 26 million Americans have diabetes and an estimated 79 million U.S. adults have

prediabetes, according to new estimates from the Centers for Disease Control and Prevention

(CDC).  The National Diabetes Fact Sheet for 2011 says that diabetes affects 8.3 percent of all

Americans and 11.3 percent among those aged 20 and older.  An estimated 7 million Americans

with diabetes do not know they have the disease.  "These distressing numbers show how important

it is to prevent type 2 diabetes and to help those who have diabetes manage the disease to prevent

serious complications such as kidney failure and blindness,"4

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Using data from an ongoing government health survey, researchers found that Asian Americans had

consistently higher rates of type 2 diabetes than white Americans from 1997 to 2008.What's more,

diabetes rates rose over time for both racial groups, reaching 8 percent among Asian adults and 6

percent among whites Americans.5

Worldwide at least 171 million people have diabetes; this figure is likely to be more than double by

2030. Unfortunately, India has the largest number of diabetic patients in the world. The disease is

such that it cannot be cured; only managed. Diabetes, which was once prevalent only among adults,

is now found commonly in children due to change in lifestyle and imbalanced eating habits.6

The International Diabetes Federation recently published findings revealing that in 2007, the

country with the largest numbers of people with diabetes is India (40.9 million), followed by China

(39.8 million), the United States (19.2 million), Russia (9.6 million) and Germany (7.4 million).

Some other alarming diabetes statistics include the fact that there is one person in the world dying of

diabetes every ten seconds. Also, there will be two new diabetic cases in the world being identified

every ten seconds. And, what’s worse, these statistics also tell us that by the year 2025, there will be

seven million new diabetic cases in the world.6

In India, there are going to be eighty percent of all diabetics from the entire world population

concentrated here - this makes India the diabetic capital of the world. Also, these diabetes statistics

show that the disease is not one that affects only the rich, though it is most likely to affect those with

a sedentary lifestyle and who consume diets that are mainly unhealthy.6

Various drugs have been extensively used for the treatment of type 2 diabetes since last long many

years. The most commonly using antidiabetic drugs are sulfonylurea, thiazolidinediones, alpha

glucosidase inhibitors, meglitinide, dipeptidyl peptidase 4 inhibitors (DPP-4) etc.7

Nateglinide is an oral antihyperglycemic agent used for the treatment of non-insulin-dependent

diabetes mellitus (NIDDM). It belongs to the meglitinide class of short-acting insulin secretagogues,

which act by binding to β cells of the pancreas to stimulate insulin release.8

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Repaglinide belongs to the meglitinide class of blood glucose-lowering drugs. Repaglinide lowers

blood glucose by stimulating the release of insulin from the pancreas. It achieves this by

closing ATP-dependent potassium channels in the membrane of the beta cells. This depolarizes the

beta cells, opening the cells' calcium channels, and the resulting calcium influx induces insulin

secretion.9

Cancer is the Latin word for crab. The ancients used the word to mean a malignancy, doubtless

because of the crab-like tenacity a malignant tumor sometimes seems to show in grasping the tissues

it invades. Cancer may also be called malignancy, a malignant tumor, or a neoplasm (literally, a new

growth). An abnormal growth of cells which tend to proliferate in an uncontrolled way and, in some

cases, to metastasize (spread).10

Cancer can involve any tissue of the body and have many different forms in each body area. Most

cancers are named for the type of cell or organ in which they start. If a cancer spreads

(metastasizes), the new tumor bears the same name as the original (primary) tumor. The frequency

of a particular cancer may depend on gender. While skin cancer is the most common type of

malignancy for both men and women, the second most common type in men is prostate cancer and

in women, breast cancer.10 Cancer frequencies does not equate to cancer mortality. Skin cancers are

often curable. Lung cancer is the leading cause of death from cancer for both men and women in the

United States today.10Benign tumors are NOT cancer; malignant tumors are cancer. Cancer is NOT

contagious.10

There are over 200 types of cancer. such as Carcinoma, Sarcoma, Leukemia, Lymphoma and

myeloma, Central nervous system cancers.11Not included in the above types listed are metastatic

cancers; this is because metastatic cancer cells usually arise from a cell type listed above and the

major difference from the above types is that these cells are now present in a tissue from which the

cancer cells did not originally develop.11

Consequently, if the terms "metastatic cancer" is used, for accuracy, the tissue from which the

cancer cells arose should be included. For example, a patient may say they have or are diagnosed

with "metastatic cancer" but the more accurate statement is "metastatic (breast, lung, colon, or other

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type) cancer."11

Report reveals that each year more than 12.7 million people undergo cancer diagnosis and over 7

million people die of cancer.12

The incidence and mortality statistics presented here for cancers worldwide were taken from the

International Agency for Research on Cancer GLOBOCAN database (version 1.2), which presents

estimates for 2008. An estimated 12.7 million new cancer cases were diagnosed worldwide in 2008.

Lung, female breast, colorectal and stomach cancers were the most commonly diagnosed cancers,

accounting for more than 40% of all cases. Worldwide, an estimated 7.6 million deaths from cancer

occurred in 2008. Lung, stomach, liver, colorectal and female breast cancers were the most common

causes, accounting for more than half of all cancer deaths.13

Breast cancer is a cancer that starts in the tissues of the breast. There are two main types of breast

cancer.Ductal carcinoma starts in the tubes (ducts) that move milk from the breast to the nipple.

Most breast cancers are of this type. Lobular carcinoma starts in the parts of the breast, called

lobules that produce milk.14

In 2012, it is estimated that among U.S. women there will be226,870 new cases of invasive breast

cancer (includes new cases of primary breast cancer among survivors, but not recurrence of original

breast cancer among survivors).14 63,300 new cases of in situ breast cancer (includes ductal

carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS), of those, about 85 percent will be

DCIS). DCIS is a non-invasive breast cancer and LCIS is a condition that increases the risk of

invasive breast cancer. Learn more about DCIS and LCIS.39,510 breast cancer deaths.14 Breast

cancer in men is rare, but it does happen. In 2012, it is estimated that among U.S. men there will be

2,190 new cases of breast cancer. 410 breast cancer deaths.15

Abraxane is an anti-cancer ("antineoplastic" or "cytotoxic") chemotherapy drug.  Abraxane is

classified as an "plant alkaloid," a "taxane" and an "antimicrotubule agent."16 Abraxane is used to

treat breast cancer after failure of combination chemotherapy for metastatic disease or relapse

within 6 months of adjuvant chemotherapy.  Prior therapy should have included an anthracycline

chemotherapy unless clinically not appropriate. Non-small cell lung cancer.16

The U.S. incidence of both diabetes mellitus and cancer is increasing. Approximately 1.6 million

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new cases of diabetes mellitus and 1.4 million of cancer are diagnosed every year. Large cohort

studies show that pancreatic, colorectal, breast, hepatobiliary, bladder, and endometrial cancers

occur more frequently in people with type 2 diabetes. Potential reasons behind this association

include common causality (shared risk factors), hyperglycemia, and other metabolic abnormalities

of type 2 diabetes that cause cancer, and cancer that causes hyperglycemia.17

Recent scientific developments particularly in the area of cytochrome P450 drug metabolizing

enzymes have revolutionized the study of drug interactions. The result has been a deluge of

published drug interaction research that has overwhelmed most health care practitioners. While it is

not possible for an individual health care practitioner to recognize all clinically significant drug

interactions, it is possible to understand the important scientific principles and mechanisms that

pertain to this topic.1

Drug-drug interactions are of potential concern whenever a person takes two or more medications

concurrently. Indeed, in a recent poll adults were asked what they would be “very concerned” about

if they were to check into a hospital or other health care facility. The number one concern (61%)

was being given the wrong medicine, but a close second at 58% was a negative interaction between

multiple drugs. 1

6.2 Review of Literature:

Literature survey was carried out on the proposed research work by referring various scientific

Research journals, Internet, Helinet facilities and science direct. Upon through survey of literature it

was revealed that, the incidence of type 2 diabetes mellitus is increasing day by day

disappointingly.18

Diabetes and cancer are common diseases with tremendous impact on health worldwide.

Epidemiologic evidence suggests that people with diabetes are at significantly higher risk for many

forms of cancer. Type 2 diabetes and cancer share many risk factors, but potential biologic links

between the two diseases are incompletely understood. Moreover, evidence from observational

studies suggests that some medications used to treat hyperglycemia are associated with either

increased or reduced risk of cancer.19

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Telithromycin may reduce clearance of Nateglenide. Consider alternate therapy or monitor for

changes in the therapeutic/adverse effects of Nateglenide if Telithromycin is initiated, discontinued

or dose changed. Voriconazole, a strong CYP3A4 inhibitor, may increase the serum concentration

of nateglinide by decreasing its metabolism. Monitor for changes in the therapeutic and adverse

effects of nateglinide if voriconazole is initiated, discontinued or dose changed.20

Literature survey also indicates that, When Rifampicin and Nateglinide are administered

simultaneously the peak plasma concentration of Nateglinide was increased by Rifampicin.21

Rifampicin (rifampin) reduced repaglinide area under the plasma concentration-time curve (AUC)

by 32-85% while it reduced nateglinide AUC by almost 25%.22

Clarithromycin may increase the effect of repaglinide. Cyclosporine may increase the therapeutic

and adverse effects of repaglinide. The macrolide, erythromycin, may increase the effect of

repaglinide. Gemfibrozil may increase the effect and toxicity of repaglinide.23

The metabolism of Abraxane (paclitaxel) is catalyzed by CYP2C8 and CYP3A4. In the absence of

formal clinical drug interaction studies, caution should be exercised when administering

ABRAXANE concomitantly with medicines known to inhibit (e.g., ketoconazole and other

imidazole antifungal, erythromycin, fluoxetine, gemfibrozil, cimetidine, ritonavir, saquinavir,

indinavir, and nelfinavir) or induce (e.g., rifampicin, carbamazepine, phenytoin, efavirenz, and

nevirapine) either CYP2C8 or CYP3A4.24

Further literature survey reveals that, there are no report about the possible drug interaction between

Abraxane and anti Diabetic agents like Nateglinide and Repaglinide.

6.3 Objective of the study:

Diabetes and cancer are common diseases with tremendous impact on health worldwide. A large

number of drugs are introduced every year, and new interactions between medications are

increasingly reported. Multiple drug regimens carry the risk of adverse interactions.25

If the diabetic patient is suffering from breast cancer, in such condition anticancer drugs like

abraxane, along with routine antidiabetic drugs like nateglinide and repaglinide is prescribed, this

multi drug therapy may lead to serious drug - drug interactions as all the drugs mentioned above are

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metabolized by enzyme CYP450.

Hence, in the present study the main objective is to understand the influence of abraxane

administration along with the anti diabetic potency of Nateglinide and Repaglinide.

The influence of Abraxane on the above mentioned anti diabetic drugs has not yet been studied and

reported. Hence the main objective of the present study is to understand the influence of Abraxane

administration alongwith the anti diabetic potency of Nateglinide and Repaglinide.

If at all any influence is noticed, the study also proposes to suggest modification at either dose or

frequency of administration of anti diabetic agents to avoid possible hazards.

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7. Materials and Methods

7.1 Source of Data:

Whole work is planned to generate data from laboratory based experimental animal models as

described in various national and international journals and books available with our college and

other reputed institutions at India through e-publishing and HELINET of RGUHS, Bangalore.

7.2 Method of collection of Data:

The blood samples for rats will be collected from retro orbital plexus/tail vein, for rabbits from

marginal ear vein. Standard procedures are adopted for estimating blood sugar levels, as mentioned

in the journals and books. The study is planned and designed in following phases.

Phase-1: In this phase rats of one group (n=6) will be treated with Abraxane (10 mg/kg B.W. P.O.)26

for seven consecutive days and its influence on the blood glucose levels will be studied.

Phase-2: In this phase, two groups are used (n=6). The rats of one group will be administered with

nateglinide (50 mg/kg B.W. P.O.)27 and the other group will be administered with repaglinide (0.1-

0.3 mg/kg B.W. P.O.) 28

Thereafter the blood samples will be withdrawn at 0, 0.5, 1, 2, 4, 6, 8, 12, 18 and 24 hours intervals

and will be analyzed for blood glucose concentration determination by GOD/POD method using

semi auto analyzer (BCA201).

This phase provides the per se influence of nateglinide and repaglinide on blood sugar level.

Phase-3: In this phase, the same animals of phase-2 study will be utilized. However, the animals of

phase-2 will be allowed for a period of one week to completely washout the previously administered

drugs from their body. Thereafter, both the groups of animals will be administered with Abraxane

(10 mg/kg B.W. P.O) 26for a period of one week. On 8th day one hour after Abraxane one group will

receive nateglinide (50 mg/kg B.W. P.O.)27 and the other repaglinide (0.3mg/kg B.W. P.O)28.

Thereafter the blood samples are collected and analyzed for glucose concentration by GOD/POD

method using semi auto analyzer (BCA201) as mentioned in phase-2. This phase is expected to

produce data regarding occurrence of interaction (if any) among administered combination.

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Phase-4: In this phase, the entire protocol of phase-2 and phase-3 will be repeated using

streptozotocin induced diabetic rats.

Phase-5: In this phase, albino rabbits of either sex, weighing between 1.5-1.8 kg will be divided into

several groups. The entire protocol ranging from phase-1 to phase-3 will be repeated to understand

the influence of Abraxane on anti diabetic effect of nateglinide and repaglinide.

.

Induction of Diabetes:

Rats fasted for 18 hours, will be subjected to single intraperitonial injection of streptozotocin (STZ)

at the dose of 50mg/kg body weight/rat. Rats that exhibit blood glucose Conc. more than 250mg/dl

after 48hrs of STZ injection will be considered as diabetic and selected for the proposed study.29 The

blood glucose concentration before and after respective treatment at above specified time intervals

will be determined by GOD/POD method.

INCLUSION CRITERIA

Normal and healthy animals of either sex weighing between 150-180 gms for rats and 1.5-1.8kg for

rabbits will be included in the study.

EXCLUSION CRITERIA

The albino rats and rabbits which do not fall the above mentioned weights are excluded from study.

STATISTICAL ANALYSIS

All values will be expressed as mean SEM from 6 animals in any group. Results will be subjected

to statistical analysis using one-way ANOVA and allowed by post hoc test (Dunnet ‘T’ test). p<0.05

will be considered as statistically significant.

7.3 Does the study require any investigation or intervention to be conducted on patients or

other humans? If so please mention briefly.

Yes, the above study requires investigation on animals like albino rats and rabbits.

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8.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes, the study is cleared from institutional animal ethics committee (IAEC copy enclosed)

List of References:

1) Philip Hansten, John Horn. Drug-Drug Interaction Mechanisms. [Online]. Available from:

URL: http://www.hanstenandhorn.com/article-d-i.html

2) Diabetes mellitus. [Online]. Available from: URL:

http://kidshealth.org/parent/diabetes_center/words_know/diabetes_mellitus.html

3) Indian Diabetics care with pride and passion. [Online]. Available from:

URL:http://indiandiabetics.com/DiabetesScene.aspx

4) Number of Americans with Diabetes Rises to Nearly 26 Million. [Online]. Available from:

URL: http://professional.diabetes.org/News_Display.aspx?CID=83450

5) Fox news. Asian Americans Show Higher Diabetes Rates. [Online]. Available from:

URL:http://www.foxnews.com/health/2011/01/14/asian-americans-higher-diabetes-rates/

#ixzz2H7kCRMdX

6) Indian Diabetics care with pride and passion. [Online]. Available from:

URL: http://indiandiabetics.com/DiabetesScene.aspx

7) Tripathi KD. Essentials of medical pharmacology. 6th Edition. New Delhi; Jaypee brothers’

medical publishers 2008; 254.

8) Available from:URL:http://www.drugbank.ca/drugs/DB00731

9) Available from:URL:http://en.wikipedia.org/wiki/Repaglinide

10) Cancer definition-cancer information.Available from:

URL:http://www.medterms.com/script/main/art.asp?articlekey=2580

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11) Availablefrom:URL:http://www.medicinenet.com/cancer/

page4.htm#what_are_the_different_types_of_cancer

12) Times of India. World cancer Day. Available from:URL:

http://timesofindia.indiatimes.com/world-cancer-day-2012/eventcoverage/11649416.cms

13) Worldwide cancer statistics. Cancer Research UK. Available

from:URL:http://www.cancerresearchuk.org/cancer-info/cancerstats/world/cancer-

worldwide-the-global-picture.

14) U.S. National Library of Medicine - The World's Largest Medical Library.Available from:

URL: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001911/

15) American Cancer Society. Cancer Facts and Figures 2012. Atlanta, GA: American Cancer

Society, 2012. Breast Cancer Statistics. Available from:

URL:http://ww5.komen.org/breastcancer/statistics.html

16) Cancer alliance for Research. Education and Survivorship. Available from: URL:

http://chemocare.com/chemotherapy/drug-info/abraxane.aspx

17) Diabetes and cancer. Available

from:URL:http://www.mayoclinic.org/medicalprofs/diabetes-and-cancer.html

18) Hertz C G, Pasquilina S, Perminder R, Katterine MM. Annual incidents and relative risk of

diabetics in people with various categories of dysglycemia - A systematic over wide and

meta analyzed of prospective studies. Diabetics research and clinical practice

2007;78(3):305-312

19) Edward G,Richard MB, Susan MG, Laurel AH, David MH et al.Diabetes and Cancer. A

consensus report.2010 by the American Diabetes Association. Available from

URL:http://care.diabetesjournals.org/content/33/7/1674.full

20) Available from:URL: http://www.drugbank.ca/drugs/DB00731

21) Mikko N, Janne TB, Mikko N, Pertti JN. Effect of rifampicin on the pharmacokinetics and

pharmacodynamics of nateglinide in healthy subjects. Available from:

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URL:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1884366/

22) Scheen AJ. Clin Pharmacokinetics. Drug-drug and food-drug pharmacokinetic interactions

with new insulin tropic agents repaglinide and nateglinide. 2007;46(2):93-108. Available

from:URL:http://www.ncbi.nlm.nih.gov/pubmed/17253883

23) Available from:URL:http://www.drugbank.ca/drugs/DB00912

24) Available from:URL:http://www.rxlist.com/abraxane-drug/side-effects-interactions.htm

25) Paul W, John G, Bertolino, James L. Liszewski. Clinically Significant Drug

Interactions.2000 Mar 15;61(6):1745-1754.Available

from:URL:http://www.aafp.org/afp/2000/0315/p1745.html

26) Sandra P, Oger J, Oger M, William C. Enhanced Oral Paclitaxel Bioavailability after

Administration of Paclitaxel-Loaded Lipid Nanocapsules .2006 [Online]. Available

from:

URL:http://www.academia.edu/182475/Enhanced_Oral_Paclitaxel_Bioavailability_After

Administration_of_Paclitaxel-Loaded_Lipid_Nanocapsules

27) Masanori I, Udai N, Yuji U, Sakae N, Mitsuo I. Nateglinide, a non-sulfonylurea rapid insulin

secretagogue, increases pancreatic islet blood flow in rats. European Journal of

Pharmacology 2005; 518:243–250.

28) Chitra V,Jaya SR, Mastan RV, Bhargavi CY. Department of Pharmacology. SRM College of

Pharmacy, SRM University, Kattankulathur, Kanchipuram, Tamilnadu, India. [Online].

Available from: URL: http://scholarsresearchlibrary.com/DPL-first-issue/DPL-16.pdf

29) Parthasarathy R, Ilavarasan R, Karrunakaran CM. Antidiabetic activity of Thespesia

Populnea bark and leaf extract against streptozotocin induced diabetic rats. International

Journal of PharmTech Research 2009; 1(4):1069-1072.

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9. Signature of Candidate( NASERA SULTANA)

10. Remarks of the GuideThe candidate is working under my direct supervision in laboratories of Luqman college of Pharmacy. Gulbarga-585102

11. Name & Designation of (in block letters)

11.1 Guide Dr. D.K. SURESH M.Pharm, PhD

PROFESSOR

11.2 Signature

11.3 Co-Guide ----

11.4 Signature ----

11.5 Head of Department Dr. D.K. SURESH M.Pharm, PhD

PROFESSOR

DEPT. OF PHARMACOLOGY LUQMAN COLLEGE OF PHARMACY,

15

GULBARGA-585102

11.6 Signature

12. 12.1 Remarks of the Chairman

& PrincipalRecommended and Forwarded

12.2 Signature

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