Contribution of Protein Binding, Lipid Partitioning, and Asymmetrical Transport to Drug Transfer into Milk in Mouse Versus Human

Purpose

Drug transfer into milk is a general concern during lactation. Because data are limited in human subjects, particularly for new drugs, experimental animal models of lactational drug transfer are critical. This study analyzed drug transfer into milk in a mouse model, as well as the contribution of similar and dissimilar host factors.

Methods

Milk/plasma drug concentration ratios (M/P) in humans were obtained from the literature, while those in mice were determined experimentally after intraperitoneal implantation of osmotic pumps containing drugs of interest. Unbound drug fractions in plasma and milk were determined in vitro for both species.

Results

M/P values were determined for 27 drugs in mice and compared with those in human. These values were increased in mice for 21 drugs; the geometric mean ratio of M/P between mice and humans was 2.03 (95% CI, 1.42–2.89) for all 27 drugs. These results were reasonably explained by the relatively high protein and lipid content in mouse milk. Moreover, species-specific asymmetrical transport systems were suggested for 9 drugs.

Conclusions

In addition to species-specific differences in milk protein and lipid content, variances in asymmetrical drug transport across the mammary epithelium may yield discordant M/P values in humans and mice.     

Factors affecting the milk-to-plasma drug concentration ratio in lactating women: physical interactions with protein and fat

The factors that affect M/P (milk-to-plasma) ratios of several compounds were assessed in vitro using samples collected from four healthy lactating women. Three drugs were studied: diazepam, phenytoin, and propranolol. Serum and skim milk protein binding were determined by equilibrium dialysis at 37 degrees C. Skim-to-whole milk concentration ratios (S/M) were determined after incubation of whole milk at 37 degrees C for 1 h. Free fractions in serum and skim milk, respectively, were 0.013 and 0.334 for diazepam, 0.142 and 0.584 for phenytoin, and 0.107 and 0.699 for propranolol. The S/M values were 0.220, 0.727, and 0.610 for diazepam, phenytoin, and propranolol, respectively. An equation was derived which relates M/P to milk and plasma pH, unbound fractions of drug in skim milk and serum, and S/M. The M/P ratios calculated from in vitro data agreed with published in vivo M/P ratios. The results indicated that milk protein binding and fat partitioning can make a substantial contribution in determining M/P, and predictions of M/P made without considering these factors may be misleading.     

Possible effect of lactational period on the milk-to-plasma drug concentration ratio in lactating women: results of an in vitro evaluation

The fat and protein composition of human milk changes dramatically in the first several weeks postpartum. In order to investigate the possible effect of this compositional change on the milk-to-plasma drug concentration ratio (M/P), the following experiment was performed. Milk samples were collected from five healthy lactating women on days 3, 5, 7, and 14 postpartum; blood samples were obtained on these days, as well as on day 1. Serum and skim milk unbound fractions (fp and fm, respectively) and the skim milk-to-whole milk drug concentration ratio (S/M) were determined in vitro in the above samples for diazepam, propranolol, and etretin, an aromatic retinoid. In addition, the composition of these milk and serum samples was also assessed. Using a previously proposed mathematical model for the distribution of drugs between milk and plasma, M/P was calculated from values for fm, fp, S/M, milk pH, and literature values for the pKa values of the compounds. The M/P was calculated for each subject on each day of sample collection. Total serum protein and alpha-1-acid glycoprotein (AAG) levels increased in the first two weeks postpartum. Mean diazepam fp values fell from 0.020 to 0.014 during this period, while propranolol fp values changed inversely with serum AAG levels. Milk whey and total proteins decreased as lactation progressed, but changes in fat levels were not statistically significant. Calculated propranolol M/P increased during the study period, predominately due to changes in milk pH and propranolol S/M.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prospective evaluation of a model for the prediction of milk:plasma drug concentrations from physicochemical characteristics.

1. Milk:plasma (M/P) drug concentration ratios predicted by a model utilizing pKa, plasma protein binding and octanol:water partition coefficients have been compared with actual M/P values for 10 basic drugs. 2. There was a close relationship between predicted and observed M/P ratios with a coefficient of determination r2 of 0.97. However, there was a proportional error. 3. The data were transformed by taking logs of predicted and observed (M/P + 1) values. Regression analysis resulted in an r2 of 0.95, an intercept on the Y-axis not significantly different from zero and a slope not significantly different from one. 4. The 95% confidence interval around a single prediction revealed an error between 150% for the lowest and 23% for the highest M/P ratios. The error is therefore lowest for the drugs likely to have the greatest transfer into milk. 5. There was no significant bias in the predictions. 6. The model was refined by multiple linear regression analysis utilising the observed M/P ratios for the 10 basic drugs in addition to those of the original drugs. The revised equation resulted in an improvement in the explained variance. 7. Protein binding was the most important single predictor. 8. The results confirm that M/P ratios for basic drugs can be predicted accurately from their physicochemical characteristics.     

Citalopram and demethylcitalopram in human milk; distribution, excretion and effects in breast fed infants

AIMS: To characterize milk/plasma (M/P) ratio and infant dose, for citalopram and demethylcitalopram, in breast-feeding women taking citalopram for the treatment of depression, and to determine the plasma concentration and effects of these drugs in their infants. METHODS: Seven women (mean age 30.6 years) taking citalopram (median dose 0.36 mg kg(-1) day(-1)) and their infants (mean age 4.1 months) were studied. Citalopram and demethylcitalopram in plasma and milk were measured by high-performance liquid chromatography over a 24 h dose interval. Infant exposure was estimated (two separate methods) as the product of milk production rate and drug concentration in milk, normalized to body weight and expressed as a percentage of the weight-adjusted maternal dose. RESULTS: Mean M/PAUC values of 1.8 (range 1.2-3) and 1.8 (range 1.0-2.5) were calculated for citalopram and demethylcitalopram, respectively. The mean maximum concentrations of citalopram and demethylcitalopram in milk were 154 (95% CI, 102-207) microg l(-1) and 50 (23-77) microg l(-1). Depending on the method of calculation, mean infant exposure was 3.2 or 3.7% for citalopram and 1.2 or 1.4% for demethylcitalopram. Citalopram (2.0, 2.3 and 2.3 microg l(-1)) was detected in three of the seven infants. Demethylcitalopram (2.2 and 2.2 microg l(-1) was detected in plasma from two of the same infants. No adverse effects were seen in the infants, all were within appropriate percentile limits for weight and all had normal Denver developmental quotients. CONCLUSIONS: The mean combined dose of citalopram and demethylcitalopram (4.4-5.1% as citalopram equivalents) transmitted to infants via breast milk is below the 10% notional level of concern. Plasma concentrations of these drugs in the infants were very low or absent and there were no adverse effects. These data support the safety of the use of citalopram in breast feeding women. Nevertheless, each decision to breast feed should always be made as an individual risk:benefit analysis.     

Prediction of adipose tissue: plasma partition coefficients for structurally unrelated drugs

Tissue:plasma (P(t:p)) partition coefficients (PCs) are important parameters describing tissue distribution of drugs. The ultimate goal in early drug discovery is to develop and validate in silico methods for predicting a priori the P(t:p) for each new drug candidate. In this context, tissue composition-based equations have recently been developed and validated for predicting a priori the non-adipose and adipose P(t:p) for neutral organic solvents and pollutants. For ionizable drugs that bind to different degrees to common plasma proteins, only their non-adipose P(t:p) values have been predicted with these equations. The only compound-dependent input parameters for these equations are the lipophilicity parameter, such as olive oil-water PC (K(vo:w)) or n-octanol-water PC (P(o:w)), and/or unbound fraction in plasma (fu(p)) determined under in vitro conditions. Tissue composition-based equations could potentially also be used to predict adipose tissue-plasma PCs (P(at:p)) for ionized drugs. The main objective of the present study was to modify these equations for predicting in vivo P(at:p) (white fat) for 14 structurally unrelated ionized drugs that bind substantially to plasma macromolecules in rats, rabbits, or humans. The second objective was to verify whether K(vo:w) or P(o:w) provides more accurate predictions of in vivo P(at:p) (i.e., to verify whether olive oil or n-octanol is the better surrogate for lipids in adipose tissue). The second objective was supported by comparing in vitro data on P(at:p) with those on olive oil-plasma PC (K(vo:p)) for five drugs. Furthermore, in vivo P(at:p) was not only predicted from K(vo:w) and P(o:w) of the non-ionized species, but also from K*(vo:w) and P*(o:w), taking into account the ionized species in addition. The P(at:p) predicted from K*(vo:w), P*(o:w), and P(o:w) differ from the in vivo P(at:p) by an average factor of 1.17 (SD = 0.44, r = 0.95), 15.0 (SD = 15.7, r = 0.59), and 40.7 (SD = 57.2, r = 0.33), respectively. The in vitro values of K(vo:p) differ from those of P(at:p) by an average factor of 0.86 (SD = 0.16, r = 0.99, n = 5). The results demonstrate that (i) the equation using only data on fu(p) as input and olive oil as lipophilicity surrogate is able to provide accurate predictions of in vivo P(at:p), and (ii) olive oil is a better surrogate of the adipose tissue lipids than n-octanol. The present study is an innovative method for predicting in vivo fat partitioning of drugs in mammals.     

Distribution and excretion of fluoxetine and norfluoxetine in human milk

AIMS: To characterize milk/plasma (M/P) ratio and infant dose, for fluoxetine and norfluoxetine, in breast-feeding women taking fluoxetine for the treatment of depression, and to determine the plasma concentration of these drugs in their infants. METHODS: Fourteen women (mean age 32.2 years) taking fluoxetine (mean dose 0.51 mg kg-1 day-1 ) and their infants (mean age 3.4 months) were studied. Fluoxetine and norfluoxetine in plasma and milk were measured by high-performance liquid chromatography over a 24 h dose interval in four patients, and by single point data collection in 10 patients. Infant exposure was estimated as the product of estimated milk production, and average drug concentration in milk, normalized to body weight and expressed as a percentage of the weight-adjusted maternal dose. RESULTS: Mean M/P values of 0.68 (95% CI 0.52-0.84) and 0.56 (95% CI 0.35-0.77) were calculated for fluoxetine and norfluoxetine, respectively. Mean total infant exposure (fluoxetine equivalents) was estimated to be 6.81% (range 2.15-12%) of the weight-adjusted maternal dose of fluoxetine. Contributions from fluoxetine and norfluoxetine were approximately equal. Fluoxetine (range 20-252 microgram l-1 ) was detected in five of the nine infants from whom samples were collected, and norfluoxetine (range 17-187 microgram l-1 ) was detected in seven of the nine infants. The highest of these concentrations was about 70% of the maternal plasma concentrations. CONCLUSIONS: The mean combined dose of fluoxetine and norfluoxetine transmitted to infants via breast milk is below the 10% notional level of concern. However, there was considerable interpatient variability in estimated infant dose and in some of the patients, the dose was >10%. Further, since adverse effects have been observed in breast-fed infants, careful monitoring of the infants is mandatory. Neonates exposed to these drugs in utero had higher concentrations of fluoxetine and norfluoxetine and are at greater risk of adverse effects.     

Recent progresses in the experimental methods and evaluation strategies of transporter functions for the prediction of the pharmacokinetics in humans

Establishing the methods for the effective screening of compounds with optimal pharmacokinetic properties is of great importance to many scientists working in new drug discovery and development. This review deals with the methods by which in vivo pharmacokinetics in humans can be predicted from in vitro studies and from in vivo animal experiments. Direct extrapolation from animal studies to human pharmacokinetics is generally difficult because of species differences in the function of molecules involved in drug metabolism and transport. To overcome this problem, a "scaling factor," which relates in vivo animal studies with in vitro experiments, is often used for the accurate prediction. Several experimental systems for the functional analyses of membrane transporters have been developed and many reports have revealed that various transporters clearly govern the tissue dispositions of drugs in humans. This review covers the impact of membrane transporters on the pharmacokinetics, control of elimination pathways, and toxicity. Indeed, by utilizing transporter-deficient animals, some studies have clarified the importance of transporters in various types of tissue-specific toxicity. Transporter-mediated drug-drug interactions are one of the most important issues in clinical situation because some reports suggested that severe clinical incidents are caused by the inhibition of transporter-mediated uptake and efflux in clearance organs (liver and kidney) and at several barriers. The review also focuses on the clinical significance of genetic polymorphisms of transporters, as these can influence the plasma and tissue concentrations of some drugs. Finally, integrated information is presented based on multiple in vitro studies, including those on transporters. This should enable the prediction of the outcomes of drug exposure in cells, tissues, and individual organisms.     

Studies on the Excretion of Diazepam and Nordazepam into Milk for the Prediction of Milk-to-Plasma Drug Concentration Ratios

The influence of varying protein and fat content in milk of New Zealand White rabbits on the milk-to-plasma drug concentration (M/ P) ratio of diazepam and its metabolite nordazepam following administration of diazepam was studied. At various time points after littering, a bolus dose (1.5 mg/kg) followed by a 26-hr infusion (1.8 mg/h) of diazepam was administered to freely moving rabbits via a jugular vein catheter. Milk and blood samples were collected to allow characterization of milk composition and quantitative determination of diazepam and nordazepam in milk and plasma. At steady state diazepam showed M/P ratios between 3.7 and 9.5, whereas nordazepam showed ratios between 2.1 and 4.3, respectively. The relative importance of milk protein binding and milk-fat partitioning for the excretion of a drug into milk depended on the drugs affinity to milk fat. A stepwise multiple regression analysis suggested that observed M/P ratios of diazepam could be explained by considering the fat content of milk alone. Nordazepam with a lower solubility in milk fat showed M/P ratios which could be best explained by considering protein and fat concentrations together. Using the data from the infusion studies, two recently published diffusional models to predict M/P ratios were evaluated. Neither model could accurately predict the M/P ratios of diazepam and nordazepam observed in rabbits. However, after extending the model described by Atkinson and Begg to take the actually measured partitioning between skim milk and milk fat into account, a great improvement in the predictive power for observed M/P ratios occurred. Therefore, to estimate the potential for a drug to accumulate in milk using the developed relationship, the following parameters should be measured: the creamatocrit, the skim-to-whole milk drug concentration ratio, and the free, nonionized fractions of a drug in plasma and in milk.     

Prediction of in vivo hepatic clearance and half-life of drug candidates in human using chimeric mice with humanized liver

Accurate prediction of pharmacokinetics (PK) parameters in humans from animal data is difficult for various reasons, including species differences. However, chimeric mice with humanized liver (PXB mice; urokinase-type plasminogen activator/severe combined immunodeficiency mice repopulated with approximately 80% human hepatocytes) have been developed. The expression levels and metabolic activities of cytochrome P450 (P450) and non-P450 enzymes in the livers of PXB mice are similar to those in humans. In this study, we examined the predictability for human PK parameters from data obtained in PXB mice. Elimination of selected drugs involves multiple metabolic pathways mediated not only by P450 but also by non-P450 enzymes, such as UDP-glucuronosyltransferase, sulfotransferase, and aldehyde oxidase in liver. Direct comparison between in vitro intrinsic clearance (CL(int,in vitro)) in PXB mice hepatocytes and in vivo intrinsic clearance (CL(int,in vivo)) in humans, calculated based on a well stirred model, showed a moderate correlation (r2 = 0.475, p = 0.009). However, when CL(int,in vivo) values in humans and PXB mice were compared similarly, there was a good correlation (r2 = 0.754, p = 1.174 × 10??). Elimination half-life (t(1/2)) after intravenous administration also showed a good correlation (r2 = 0.886, p = 1.506 × 10??) between humans and PXB mice. The rank order of CL and t(1/2) in human could be predicted at least, although it may not be possible to predict absolute values due to rather large prediction errors. Our results indicate that in vitro and in vivo experiments with PXB mice should be useful at least for semiquantitative prediction of the PK characteristics of candidate drugs in humans.     

Organic Cation Transporter/Solute Carrier Family 22a is Involved in Drug Transfer into Milk in Mice

Drug transfer into milk is a general concern during lactation. So far, breast cancer resistance protein (Bcrp) is the only transporter known to be involved in this process, whereas participation of other transporters remains unclear. We investigated the importance of organic cation transporter (Oct) in drug transfer into milk in mice. The mammary glands of lactating versus nonlactating FVB strain mice revealed elevated mRNA levels of Oct1 and Bcrp, whereas Oct2 and Oct3 mRNA levels were decreased. Specific uptake of cimetidine, acyclovir, metformin, and terbutaline was observed in human embryonic kidney 293 cells transfected with murine Oct1 or Oct2. The milk‐to‐plasma concentration ratio (M/P) values of cimetidine and acyclovir were significantly decreased in Bcrp knockout and Oct1/2 double‐knockout (DKO) mice compared with control FVB mice, whereas the M/P values of terbutaline and metformin were significantly decreased in Oct1/2 DKO mice alone. These are the first to suggest that Oct1 might be involved in secretory transfer of substrate drugs into milk.     

A novel index for expressing exposure of the infant to drugs in breast milk.

1. We present a novel index for expressing the exposure of the infant to drugs in breast milk, which unifies two independent factors: a pharmacokinetic parameter, drug clearance, and a physiochemical parameter, i.e. milk-to-maternal plasma drug concentration ratio (M/P ratio). 2. During breast-feeding by a woman receiving therapeutic doses of a drug at steady state this index is given by: Exposure index = A x (M/P ratio)/CLI where A is a coefficient (10 ml kg-1 min-1) and CLI is drug clearance in the infant (ml kg-1 min-1). 3. This equation indicates a hyperbolic relationship between drug clearance and the exposure level of the breast-fed infant at a given M/P ratio of drug, emphasizing the importance of drug clearance as a determinant of infant exposure.     

Development of an in vitro cell culture model to study milk to plasma ratios of therapeutic drugs

Objective:

To create an in vitro cell culture model to predict the M/P (concentration of drug in milk/concentration in maternal plasma) ratios of therapeutic drugs viz. rifampicin, theophylline, paracetamol, and aspirin.

Materials and Methods:

An in vitro cell culture model using CIT3 cells (mouse mammary epithelial cells) was created by culturing the cells on transwells. The cells formed an integral monolayer, allowing only transcellular transport as it happens in vivo. Functionality of the cells was confirmed through scanning electron microscopy. Time wise transfer of the study drugs from plasma to milk was studied and compared with actual (in vivo) M/P ratios obtained at reported t_max for the respective drugs.

Results:

The developed model mimicked two important intrinsic factors of mammary epithelial cells viz. secretory and tight-junction properties and also the passive route of drug transport. The in vitro M/P ratios at reported t_max were 0.23, 0.61, 0.87, and 0.03 respectively, for rifampicin, theophylline, paracetamol, and salicylic acid as compared to 0.29, 0.65, 0.65, and 0.22, respectively, in vitro.

Conclusion:

Our preliminary effort to develop an in vitro physiological model showed promising results. Transfer rate of the drugs using the developed model compared well with the transfer potential seen in vivo except for salicylic acid, which was transferred in far lower concentration in vitro. The model has a potential to be developed as a non-invasive alternative to the in vitro technique for determining the transfer of therapeutic drugs into breast milk.KEY WORDS: Cell culture, milk-plasma ratio, CIT3 cells, in vitro, M/P ratios, reversed phase-High performance liquid chromatography     

Hydromorphone transfer into breast milk after intranasal administration

STUDY OBJECTIVES: To determine the distribution of hydromorphone into breast milk and the potential exposure of the suckling infant, and whether the distribution of hydromorphone into milk can be predicted accurately by a passive diffusion model. DESIGN: Single-dose, pharmacokinetic study. SETTING: University clinical research unit. PATIENTS: Eight lactating, nonsmoking, healthy women aged 24-32 years. INTERVENTION: Hydromorphone HCl 2 mg was given intranasally to the women to characterize its pharmacokinetics and extent of its transfer into breast milk. MEASUREMENTS AND MAIN RESULTS: Plasma and milk samples were analyzed using liquid chromatography with tandem mass spectrometry detection. The milk:plasma ratio (M:P) was calculated as the total area under the concentration-time curve (AUC) of the milk divided by the total AUC of the plasma. Predicted in vitro M:P ratios were calculated using a diffusion model. Protein binding in milk and plasma, partitioning into milk fat (whole milk:skim milk ratios), as well as pH partitioning between plasma and milk were incorporated in the model. Protein binding was determined by equilibrium dialysis. Protein binding was minimal in both milk and plasma, with unbound fractions of 1 and 0.84, respectively There was little partitioning into milk fat, as demonstrated by the whole milk:skim milk ratio of 0.98. The observed and predicted M:P ratios +/- SD for hydromorphone were 2.57 +/- 0.47 and 1.11 +/- 0.28, respectively. The 95% confidence interval for the observed M:P ratio overlapped the confidence interval of the predicted M:P ratio, a finding that supports a role for both passive diffusion and active transport as mechanisms of hydromorphone transfer into milk. CONCLUSION: Hydromorphone distributes rapidly from plasma into breast milk; however, the drug does not partition into fat. The suckling infant would receive approximately 0.67% of the maternal dose of hydromorphone (adjusted for body weight). As this is a limited exposure, further studies are needed to determine any potential impact to an infant who is fed breast milk from a mother treated with hydromorphone.     

Paroxetine in human milk

AIMS: The primary aims of the study were to estimate the exposure of infants to paroxetine via breast milk and to determine the maternal milk:plasma ratio (M/P) of paroxetine. Secondary aims were to compare single point and area under the curve (AUC) estimates of M/P, to assess variability of M/P in fore and hind milk, and to compare the observed M/P with that predicted by a model. METHODS: Two studies were performed. In one study, six nursing mothers who were being treated with paroxetine were studied over a 24 h dose interval at steady-state. The total amount of paroxetine in the milk was measured, which represented the 'dose' to the infant. The M/PAUC was calculated and compared with a predicted value. In the second study, four nursing mothers who were being treated with paroxetine, were studied at steady-state, around a normal infant feeding time. A single plasma sample and a prefeed milk sample were taken approximately 3 h after the morning dose of paroxetine, and a postfeed milk sample taken around 1 h later. The dose received by the infant was estimated from the average milk concentrations of the pre and postfeed samples using standard assumptions, and M/P calculated directly. Plasma concentrations of paroxetine were measured in 8 of the 10 infants in the two studies. RESULTS: The mean dose of paroxetine received by the infants in the first study was 1.13% (range 0.5-1.7) of the weight adjusted maternal dose. The mean M/PAUC was 0.39 (range 0.32-0.51). The predicted M/P was 0.22. The mean dose of paroxetine received by the infants in the second study was 1.25% (range 0.38-2.24) of the weight adjusted maternal dose. The mean M/P was 0.96 (range 0.31-3.33) and did not differ between fore and hind milk. The drug was not detected in the plasma of seven of the infants studied and was detected but not quantifiable (<4 microg l-1 ) in one infant. No adverse effects were observed in any of the infants. CONCLUSIONS: Measured M/P and estimated infant dose were similar in the two studies, although the range was wider for the single point study. Paroxetine can be considered 'safe' during breast feeding because the dose transferred to the infant is well below the recommended safety limit of 10% of the weight adjusted maternal dose, concentrations in the infants were generally undetectable, and no adverse effects were reported.     

Stereoselective interaction of pantoprazole with ABCG2. I. Drug accumulation in rat milk

Active transport of drug into milk is a major concern in breastfeeding. Abcg2 plays a critical role in drug transfer into rat milk, which is consistent with evidence in humans. Although it is estimated that approximately half of all therapeutic agents are chiral, there have been few reports of stereoselective interactions with ABCG2. The purpose of this study was to investigate the interaction of pantoprazole (PAN) isomers with Abcg2 in in vitro and in vivo experiments. Pantoprazole isomer flux was characterized using Abcg2-Madin-Darby canine kidney II (MDCKII) cells in Transwell plates. In a crossover design, Sprague-Dawley lactating rats were used to study PAN accumulation in milk after an intravenous infusion of pantoprazole mixture in the presence/absence of Abcg2 inhibitor [N-(4-[2-(1,2,3,4-tetrahydro-6,7-dimethoxy-2-isoquinolinyl)ethyl]-phenyl)-9,10-dihydro-5-methoxy-9-oxo-4-acridine carboxamide (GF120918)]. Samples were analyzed by high-performance liquid chromatography/liquid chromatography-mass spectrometry. The results indicated that pantoprazole isomers were transported in an identical fashion in vector-MDCKII cell lines, whereas a significant difference in flux was observed in Abcg2-MDCKII cell line. The administration of GF120918 slightly increased the concentration of both isomers in serum, but no statistical difference was observed. However, the systemic clearance of (+)PAN (0.57 ± 0.1) was larger than (-)PAN (0.44 ± 0.12) (P < 0.01). Milk to serum ratio (M/S) of (-)PAN (1.36 ± 0.20) was 2.5-fold greater than that of (+)PAN (0.54 ± 0.09) (P < 0.01). Administration of GF120918 decreased M/S of (-)PAN to 0.50 ± 0.08 (P < 0.001) and (+)PAN to 0.38 ± 0.07 (P > 0.05). In conclusion, Abcg2, which is responsible for differential accumulation in milk, interacts stereoselectively with PAN isomers. Stereoselective transport of ABCG2 may have broader consequences in drug disposition.     

Enantioselective quantification of chiral drugs in human plasma with LC-MS/MS

Today, approximately 60% of synthetic drugs are chiral and 88% of these chiral synthetic drugs are used therapeutically as racemates. However, for many racemic drugs, their stereospecific plasma pharmacokinetics in humans are not known due to the limitations of the analytical methods. Nowadays, liquid chromatography (LC)-tandem mass spectrometry (MS/MS) methods based on various chiral stationary phases (CSPs), with a high degree of specificity and sensitivity, have been widely used in enantioselective determination of chiral drugs and/or their metabolites in human plasma. The technologies and issues when coupling chiral chromatography with MS/MS detection in bioanalytical methods will be reviewed herein. The introduction and applications of various CPSs, including polysaccharide-, macrocyclic glycopeptide-, protein- and cyclodextrin-based phases, are described here. This review also includes a discussion of interface and matrix effects in enantioselective LC-MS/MS methods.     

Clinical pharmacokinetics of leflunomide

Leflunomide is the first disease-modifying antirheumatic drug to be approved for rheumatoid arthritis in the past 10 years. Orally administered leflunomide is almost completely converted into its active metabolite A77 1726 (hereafter referred to as M1). M1 displays linear pharmacokinetics at the dosages of leflunomide used in clinical practice. It has a long elimination half-life (approximately 2 weeks), reaching a steady state after approximately 20 weeks. M1 is highly bound to plasma proteins. The pharmacokinetics of M1 are not affected by food intake, and dosage requirements are not influenced by age or gender. Approximately 90% of a single dose of leflunomide is eliminated, 43% in urine, primarily as leflunomide glucuronides and an oxalinic acid derivative of M1, and 48% in faeces, primarily as M1. Elimination can be dramatically increased by using charcoal or cholestyramine. In vitro studies have shown no major influence of leflunomide on the metabolism of analgesics, nonsteroidal anti-inflammatory drugs and methotrexate, drugs usually used in the treatment of rheumatoid arthritis. In clinical studies with a limited number of patients using these drugs concomitantly, no safety problems appeared. Nonspecific inducers of cytochrome P450 (CYP) and some drugs metabolised by CYP2C9 affect the metabolism of M1, and caution should be used in patients cotreated with them. Additional in vitro and in vivo pharmacokinetic studies are needed to better understand the nonenzymatic and enzymatic metabolism of leflunomide. Additional clinical trials should be performed in order to find new indications for leflunomide in other autoimmune diseases, and new combination therapeutic strategies in rheumatoid arthritis. This review is a summary of current knowledge of the pharmacokinetics of leflunomide, focusing primarily on humans and in particular on patients with rheumatoid arthritis.     

Transfer of reboxetine into breastmilk, its plasma concentrations and lack of adverse effects in the breastfed infant

Objective To investigate the transfer of reboxetine into milk, the absolute and relative infant doses via milk and to assess plasma concentrations and adverse unwanted effects in the breastfed infant.Methods Multiple samples of blood and milk were obtained over a dose interval at steady-state from four women who were taking reboxetine for postnatal depression. Drug concentrations in plasma and milk were measured by high performance liquid chromatography and milk/plasma ratio (M/P), absolute infant dose and relative infant dose were estimated by standard methods. Their four, breastfed, infants were also examined clinically, and a blood sample was taken for drug analysis.Results The median (range) dose taken by the women was 6 (4-10) mg/day. There was no significant difference in reboxetine concentration between paired fore-and hind-milk samples. The mean (95% CI) M/P was 0.06 (0.03, 0.09). Absolute infant dose was 1.7 (0.7, 2.4) μg/kg/day for reboxetine while the relative infant dose was 2.0% (1.3, 2.7%). Three of the infants met normal developmental milestones and no adverse effects were seen in any infant. The fourth infant had developmental problems that were not associated with the maternal reboxetine therapy. The concentrations of reboxetine in plasma from the four infants were <4 μg/l, 2.6 μg/l, 2.3 μg/l and 5 μg/l, respectively.Conclusion The study suggests that reboxetine use by lactating women is safe for the breastfed infant. Nevertheless, our study had only four mother/baby pairs, and each decision to breastfeed should always be made on the basis of an individual risk/benefit analysis.