Poster Presentations Anti-Infective Drugs and Vaccination

POSTER PRESENTATIONS ANTI-INFECTIVE DRUGS AND VACCINATION

10 11 PLASMA CONCENTRATIONS OF PROTEASE STEADY STATE EFAVIRENZ INHIBITORS OVER DIFFERENT AGE CLASSES PHARMACOKINETICS PROFILE AMONG HIV D. Keller1, P. Langmann2, W. Heinz1, A. Helle1,T.Lo¨we1, PATIENTS IN ETHIOPIA 1 3 1 S. Wiebecke , A. Trein and H. Klinker A. Eyakem1, W. Amogne1, G. Yimer1, E. Makonnen1, 1 Universita¨tsklinikum Wu¨rzburg, Medizinische Klinik und Poliklinik G. Aderaye1, L. Bertilsson2, J. Burhenne3 and E. Aklillu2 2 II - Infektiologie, Josef-Schneider-Straße 2 - D20, 97080 Wu¨rzburg, Praxis 1Faculty of Medicine, Addis Abeba, Ethiopia, 2Department of Laboratory fu¨r Gastroenterologie und Infektiologie, Am tiefen Weg 2, 97753 Karlstadt, Medicine, Karolinska Institutet, Stockholm, Sweden, 3Department of 3 Gemeinschaftspraxis, Schwabstraße 57, 70197 Stuttgart, Germany Internal Medicine VI, Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Introduction Protease inhibitors (PIs) like Amprenavir (APV), Atazanavir Germany (ATV), Darunavir (DRV), Indinavir (IDV), Lopinavir (LPV), Nelfinavir (NLF), Saquinavir (SQV) and Tipranavir (TPV) are widely used in highly active Introduction The recommended therapeutic plasma concentration antiretroviral therapy (HAART) of HIV-infected patients. To improve range of efavirenz at steady state for optimal treatment success and individualized therapy it is crucial to know how age affects drug levels. minimal toxicities is supposed to be between 1000 and 4000 ng/ml. Methods and Materials In a retrospective study we analyzed 4741 The present study was designed to investigate the steady state plasma consecutive steady state plasma concentrations of eight PIs during rou- concentrations of efavirenz on weeks 4 and 16 after initiating efavi- tinely performed Therapeutic Drug Monitoring of HIV-patients. Deter- renz-based highly active antiretroviral therapy (HAART) in Ethiopian HIV mination of trough levels was conducted by HPLC. For statistical patients. analysis patients were assigned to at most four groups of different Methods and Materials Treatment naı¨ve adult HIV patients were age. Median (med) and Inter-Quartile-Range (IQR) are reported. Besides recruited prospectively to start efavirenz based HAART receiving descriptive statistical analysis nonparametric Mann--Whitney-U test was 600 mg daily. 16 h ± 1 h post dose plasma samples were collected used to detect differences between two groups. 4 weeks (N = 118) and at 16 weeks (N = 81) after initation of efavirenz Results Significant higher levels of ATV were found in the group of treatment. Efavirenz steady state plasma concentrations were deter- patients younger than 30 years (n = 28, med (IQR) = 1902 (2113) ng/ml) mined using LC/MS/MS. than in the group between 30 and 40 years (n = 115, med (IQR) = 1004 Results The mean plasma steady state concentration of efavirenz on (1095) ng/ml; P = 0.007). Drug levels remained stable in the two classes of week 4 was found to be 1475 ± 117 ng/ml (SEM) while on week 16, it older patients [40--50 years: n = 148, med (IQR) = 1184 (1457) ng/ml; was 1702 ± 169 ng/ml (SEM). The percentage of participants whose >50 years: n = 89, med (IQR) = 1093 (1420) ng/ml)]. An obvious differ- steady state plasma concentration of efavirenz with <1000, between ence in the drug level of NLF could not be proved to be significant 1000 and 4000, and >4000 ng/ml on week 4 were 45.5%, 54.2% and [<40 years: n = 17, med (IQR) = 1839 (2201) ng/ml; >40 years: n = 26, 4.2%, respectively, while on week 16, they were 34.6%, 59.3% and med (IQR) = 997 (1159) ng/ml); P = 0.08]. Plasma concentrations of 6.2%, respectively. remaining PIs showed stable levels or only few fluctuations. Conclusion Our finding showed that even though over 50% of Conclusion Pharmacokinetic parameters of most investigated PIs are patients had steady state plasma concentration of efavirenz within the independent from age. However ATV and NLF showed higher levels in therapeutic range, significant proportion of patients had sub-therapeu- younger patients than in older. For ATV this difference was even highly tic levels. We are compiling the results of clinical, immunological and significant. virological outcomes to conclude whether appreciable number of patients fail to respond to the treatment or the claimed therapeutic range is invalid at least in Ethiopians.

6 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

12 13 THE AUTO INDUCTION OF EFAVIRENZ IDENTIFICATION OF INCREASED SERUM METABOLISM AND THE RESULTING EFFECT CONCENTRATIONS OF LINEZOLID IN ON THE EFAVIRENZ STEADY STATE LEVELS IN PATIENTS WITH COMMON PREDISPOSING TANZANIAN PATIENTS RISK FACTORS FOR ADVERSE DRUG REACTION E. Ngaimisi1,2, S. Mugusi3,4, O. Minzi1, P. Sasi1, M. Janabi3, BY SYNERGISTIC USE OF CLINICAL F. Mugusi1, M. Bakari1, E. Aris3, E. Sandstrom4, L. Bertilsson2, 5 2 PHARMACOLOGICAL WARD ROUNDS AND J. Burhenne and E. Aklillu 1Departments of Internal Medicine and Pharmacology, Muhimbili THERAPEUTIC DRUG MONITORING (TDM) University of Health and Allied Sciences, Dar es Salaam, Tanzania, U. Tro¨ger, I. Reiche, S. C. Postel and S. M. Bode-Bo¨ger 2Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Otto-von-Guericke-Universita¨t, Institut fu¨r Klinische Pharmakologie, Sweden, 3Department of Internal Medicine, Muhimbili National Hospital, Leipziger Str. 44, 39120 Magdeburg, Germany Dar es Salaam, Tanzania, 4Department of Infectious Diseases, Karolinska University Hospital So¨dersjukhuset, Stockholm, Sweden, Introduction Clinical pharmacological ward rounds and TDM are useful 5Department of Internal Medicine VI, Clinical Pharmacology and tools to manage an individualised drug therapy. No requirement of Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld dose adjustment is assumed for the anti-infective linezolid in patients with hepatic or renal dysfunction. However, severe adverse effects such 410, 69120 Heidelberg, Germany as thrombocytopenia have been reported in these patients. Methods and Materials Patient records were screened in Intensive Introduction Despite good initial clinical recovery some HIV infected Care Units of University Hospital Magdeburg in regular clinical pharma- patients suffer from treatment failure following a long term antiretrovi- cological ward rounds. 20 patients receiving multiple doses of 600 mg ral therapy. Efavirenz induces its own metabolism thus reducing its linezolid every 12 hours intravenously with at least one determination plasma level by 20--40% after 10 days. Patients with efavirenz levels of serum trough levels in therapeutic drug monitoring were selected. below 1 lg/ml and above 4 lg/ml are prone to treatment failure and They were checked for common risk factors of adverse drug reactions central nervous system toxicity, respectively. We hereby report the long and drug toxicity like renal or hepatic dysfunction or haematological term efavirenz auto induction effect on the proportion of Tanzanian status. Risk factors were matched with trough levels according to pos- patients in the sub optimal, normal and toxic concentration ranges. sible drug accumulation. Methods and Materials A cohort of HAART naı¨ve patients with Results Thirteen patients meet the criteria. Serum trough levels were CD4 < 200 cell/ml and normal liver and renal functional tests was almost all above the MIC90-value of 2 lg/ml required for most suscep- recruited (n = 63). The patients were initiated on the efavirenz based tible strains of methicillin-resistant Staphylococcus aureus and Entero- HAART and 16 hr post dose plasma efavirenz concentration and its cocci over more than 75% of the administration time interval. Linezolid metabolic ratio ([EFV]/[8-OH-EFV]) were determined at the 4th and trough levels were increased in patients with hepatic dysfunction and 16th week. those with deteriorated haematological status. There was a poor rela- Results Most patients (62%) had lower plasma efavirenz concentration tion of renal dysfunction and linezolid accumulation. Most of the and metabolic ratio (73%) at 16th compared to their respective value patients with renal failure received dialysis. Dialysis seems to reduce at the 4th week (P = 0.001). The proportion of patients with efavirenz linezolid serum concentrations very efficiently. concentration <1 lg/ml, between 1 and 4 lg/ml, and >4 lg/ml at 4th Conclusion Periodic clinical pharmacological ward rounds and TDM and 16th week were 8% versus 17%, 57% versus 67% and 35% versus are suitable tools for detecting risks of drug accumulation. Linezolid 16% respectively. should be carefully monitored in risk patients particularly in those with Conclusion The proportion of patients with sub-therapeutic efavirenz liver dysfunction. Therapeutic ranges and toxic limits should be estab- plasma concentration at week 4 increased by more than 2 fold at week lished. 16. While the proportion of subjects with above the normal plasma concentration range reduced by half after 16 weeks of efavirenz initia- tion. The results indicate that efavirenz auto induction continues beyond the reported 10 days. This cumulative auto-induction may influence the long term HAART treatment outcome.

2009 The Authors 7 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

14 15 DETERMINANTS OF VERY LOW RISK OF INCIDENT AUTOIMMUNE DISEASES VORICONAZOLE CONCENTRATIONS IN AFTER HEPATITIS B VACCINATION -- A LARGE ROUTINE THERAPEUTIC DRUG MONITORING COHORT STUDY IN THE UK GENERAL (TDM) PRACTICE RESEARCH DATABASE A. Hassan, J. Burhenne, K.-D. Riedel, J. Weiss, G. Mikus, M. Egbring, A. Ceschi, G. A. Kullak-Ublick and S. Russmann W. E. Haefeli and D. Czock Universita¨tsspital Zu¨rich, Klinische Pharmakologie und Toxikologie, Department of Internal Medicine VI, Clinical Pharmacology and Ra¨mistrasse 100, 8091 Zu¨rich, Switzerland Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany Introduction A close temporal relationship between hepatitis B vaccination (HBVac) and several incident autoimmune diseases including Introduction Reasons for very low concentrations in voriconazole TDM rheumatoid arthritis, systemic lupus erythematosus (SLE), polymyalgia, include rapid metabolism (due to genetic polymorphisms or enzyme glomerulonephritis, multiple sclerosis, polyradiculoneuropathy and type induction) and nonadherence to the prescribed therapy, which cannot I diabetes mellitus has been documented in a number of case reports be distinguished by voriconazole concentrations alone. In the present and case series. Several epidemiological studies have evaluated a possi- study we developed a method to distinguish between rapid metabo- ble link between HBVac and multiple sclerosis. However, studies on lism and nonadherence by quantification of voriconazole metabolites. other autoimmune disorders following HBVac are sparse. In addition, patients were genotyped in order to assess the prevalence Methods and Materials We conducted a historical cohort study in the of CYP2C19 ultrarapid metabolizers (UM) in this population. population-based UK General Practice Research Database. We identified Methods and Materials We retrospectively evaluated patients whose an exposed cohort of 38 277 patients between the age of 6 and voriconazole concentrations were <0.2 lg/ml in routine TDM (as quan- 60 years and no prior history of rheumatoid diseases with a first-time tified by HPLC). Voriconazole and three of its metabolites were quanti- recording of HBVac. The date of the first HBVac was defined as the fied in residual blood using a highly sensitive LC/MS/MS method index date. We then identified an unexposed comparison cohort of (LLOQ = 0.03 lg/ml). Genetic polymorphisms of CYP2C19 (*2, *3, *17) 112 185 patients without HBVac, matched on age, gender, index date were determined by melting curve analysis using the hybridisation and practice to the exposed cohort. Within those cohorts we searched probe format and by PCR-RFLP respectively. for incident cases of autoimmune diseases (rheumatoid arthritis, Results A total of 585 plasma samples from 273 patients were ana- HLAB27 associated rheumatoid diseases, rheumatoid collagenoses, glo- lyzed between 2002 and 2008 and in 19.4% of the samples voriconaz- merulonephritis and polyradiculoneuritis) within 12 months after the ole concentrations <0.2 lg/ml were found. In 10% of these samples index date. nonadherence was strongly suspected because both, voriconazole and Results We found 23 patients with a first-time diagnosis of the studied metabolite concentrations, were below 0.03 lg/ml. CYP2C19 genotyp- autoimmune diseases within 12 months after the index date in the ing of 13 patients where residual EDTA blood was available led to clas- HBVac exposed cohort (absolute 12-month risk = 0.06%), versus 55 sification of patients as UM in 61% (*1*17,*17*17), EM in 31% (*1*1), such patients in the unexposed cohort (absolute 12-month IM in 8% (*1*2), and PM in 0%. The prevalence of UM was significantly risk = 0.05%). The relative risk associated with HBVac was 1.23 (95% higher as compared to a reference population (P = 0.02; chi-square confidence interval 0.75 to 1.99). Additional analyses stratified on num- test). ber of HBVac and different autoimmune disease groups also showed Conclusion Quantification of voriconazole metabolites allowed for no significant association between HBVac and autoimmune diseases. detection of suspected nonadherence in 10% of patients with very low Conclusion This study found no significant association between HBVac voriconazole concentrations. In the remaining patients rapid metabo- and the studied autoimmune diseases. Our results provide reassurance lism due to the CYP2C19*17 polymorphism appears to play a signifi- regarding ongoing safety concerns, particularly in light of the fact that cant role. several countries still have not implemented the World Health Organi- zation’s recommendation of universal HBVac because of such concerns.

8 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

DRUGS IN CARDIOVASCULAR DISEASES

16 17 INFLUENCE OF UDP- MUSCULAR SYMPTOMS IN FAMILY PRACTICE GLUCURONOSYLTRANSFERASE (UGT)- PATIENTS WITH OR WITHOUT STATIN POLYMORPHISMS ON ATORVASTATIN PRESCRIPTION -- A CROSS-SECTIONAL STUDY LACTONIZATION AND IMPLICATIONS FOR D. Moßhammer1, G. Lorenz1, S. Meznaric1, J. Schwarz1 and K. Mo¨rike2 DRUG RESPONSE 1 Universita¨tsklinikum Tu¨bingen, Lehrbereich Allgemeinmedizin, S. Riedmaier1, K. Klein1, U. Hofmann1, J. E. Keskitalo2, O¨ sterbergstraße 9, 72074 Tu¨bingen, Germany, 2Universita¨tsklinikum P. J. Neuvonen2, M. Schwab1,3, M. Niemi2 and U. M. Zanger1 Tu¨bingen, Institut fu¨r Experimentelle und Klinische Pharmakologie und 1Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology and Toxikologie, Abteilung Klinische Pharmakologie, Otfried-Mu¨ller-Straße 45, University Tuebingen, Stuttgart, Germany, 2Department of Clinical 72076 Tu¨bingen, Germany Pharmacology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland, 3Department Clinical Pharmacology, University Introduction In family practice patients, statin prescription is associ- Hospital, Tuebingen, Germany ated with musculoskeletal complaints (MC) as compared to non-prescription (odds ratio 1.5, 95% CI 1.1--2.0)1. Whether intensity, however, Introduction Response to statin therapy is highly variable in of MC differs between statin users and non-users is unknown. patients. This is largely unexplained, although recent evidence sug- Methods and Materials In a cross-sectional study, 1135 patients in 26 gested an involvement of metabolites. All statins can form inactive offices of family practitioners were interviewed using a standardized acyl-lactones which are found in vivo. Here we investigated atorvast- questionnaire. atin acyl-lactonization previously shown to be partially catalyzed by Results 411 (40%) of participating patients (n = 1031) reported hav- glucuronidation. ing experienced MC during the previous 4 weeks, 106 (26%) of Methods and Materials Using recombinant UGTs and a large human whom had received a statin prescription. Reporting severe or very liver collection we searched for the major enzyme responsible for lact- severe MC was associated with statin prescription (odds ratio 1.6; CI onization of atorvastatin. We analyzed several described common poly- 1.2--2.4) as compared with MC-free patients with statin prescription morphisms of UGT1A3 by MALDI-TOF MS analysis and determined (31% versus 21%, n = 47 and n = 133, respectively). Among MC mRNA and protein expression as well as atorvastatin lactonization in patients (n = 411), those with a statin prescription reported ameliora- UGT1A3 haplotypes. In healthy volunteers having received 20 mg ator- tion of MC while recumbent (OR 2.1, CI 1.2--3.5) (26%, n = 28) as vastatin, metabolite concentrations were quantified. Participants were compared with statin non-prescription (15%, n = 45). No significant genotyped for UGT1A3 polymorphisms and analyzed for haplotypic dif- associations were found in other items, such as localization, charac- ferences in metabolite formation. ter, physical activity, and frequency. Recipients of analgesic prescrip- Results Atorvastatin-lactone concentrations correlated well with tions among MC patients rose from those without underlying UGT1A3 mRNA (r = 0.52; P < 0.0001) and protein (r = 0.61; s s musculoskeletal disorder (OR 2.2, CI 1.0--4.6 without statin, OR 2.8, P < 0.0001), but not with UGT1A1. Polymorphism analysis for UGT1A3 CI 1.0--7.7 with statin) to those with musculoskeletal disorder (OR revealed significantly increased UGT1A3 mRNA and protein in liver 5.4, CI 3.1--9.3 without statin, OR, 8.3, CI 4.3--16.1 with statin). The samples carrying UGT1A3*2 or *6 and significantly increased atorvasta- reference group were 251 patients without muscular symptoms and tin-lactone formation in UGT1A3*2 carriers. This contradicts previous without pre-existing musculoskeletal disorders. reports showing decreased activity and/or expression of UGT1A3 vari- Conclusion The prescription of a statin appears to be associated with ants by recombinant methods (Caillier et al., Pharmacogenet Genomics reporting severe or very severe MC. The data do not allow to establish 2007). We therefore confirmed our findings by restrospectively geno- a causal relationship. typing participants of an in vivo atorvastatin study (Keskitalo et al., CPT Reference 2008). As for human liver samples, UGT1A3*2 carriers showed signifi- 1. Moßhammer D, Lorenz G, Meznaric S, Schwarz J, Muche R, Mo¨rike K. cantly higher atorvastatin-lactone and 2-OH-atorvastatin-lactone levels Statin use and its association with musculoskeletal symptoms -- a compared to UGT1A3*1 homozygotes. According to recent studies, sta- cross-sectional study in primary care settings. Family Practice 2009; tin lactones have higher potency to induce myotoxicity as compared 26: 88--95. to the acid forms. Conclusion Our results indicate a way to identify patients at increased risk for adverse reactions to statin treatment by UGT1A3 genotyping. References 1. Caillier et al, Pharmacogenet Genomics 2007. 2. Keskitalo et al, CPT 2008. Acknowledgments Supported by BMBF (HepatoSys 0313080I) and the Robert-Bosch Foundation, Stuttgart, Germany.

2009 The Authors 9 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

18 19 BAROREFLEX LOADING DURING ALPHA-2 TELOMERE LENGTH AND LEFT VENTRICULAR ADRENORECEPTOR STIMULATION UNMASKS STRUCTURE IN HYPERTENSIVE PATIENTS IMPAIRED PARASYMPATHETIC HEART RATE UNDER PHARMACOTHERAPY ACCORDING TO RESERVE IN MIDDLE-AGED SUBJECTS GUIDELINES J. Tank1, K. Heusser1, A. Diedrich2, F. C. Luft3 and J. Jordan1 M. Huber1, I. Winther1, R. Reibis2,V.Do2, J. Bolbrinker1, 1MH-Hannover, Institut fu¨r Klinische Pharmakologie, Carl Neuberg Str. 1, M. Wehland1, K. Wegscheider3,H.Vo¨ller2 and R. Kreutz1 30625 Hannover, Germany, 2Division of Clinical Pharmacology, 1Charite-Universita¨tsmedizin Berlin, Institute of Clinical Pharmacology and Department of Medicine, Vanderbilt University School of Medicine, Toxicology, Chariteplatz 1, 10117 Berlin, 2Klinik am See, Rehabilitation Nashville, TN, USA, 3Medical Faculty of the Charite´, Campus-Buch, Center for Cardiovascular Diseases, Seebad 84, 15562 Ru¨dersdorf bei Experimental Clinical Research Center, Lindenberger Weg 80, 13125 Berlin, Berlin, 3Department of Medical Biometry and Epidemiology, University Germany Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany Introduction Parasympathetic heart rate regulation deteriorates with increasing age through unknown mechanisms. Baroreflex loading dur- Introduction Telomere length, a parameter for biological ageing, has ing alpha-2 adrenoreceptor stimulation provides a graded increase in been associated with cardiovascular disease. We tested the impact of parasympathetic activity and therefore may distinguish between func- telomere length on left ventricular structure in hypertensive patients tional and structural causes. under pharmacotherapy according to guidelines. Methods and Materials We applied this approach in nine younger (six Methods and Materials We analyzed a cohort of 1106 patients (83.3% men, three women, 31 ± 2 years, 24 ± 1 kg/m2) and nine middle-aged male) with established essential hypertension. Patients were treated (two women and seven men, 49 ± 2 years, 27 ± 2 kg/m2) healthy sub- according to guidelines. Parameters of left ventricular structure were jects. Incremental intravenous phenylephrine infusions with and without determined by echocardiography. Mean leukocyte telomere length was clonidine (1--2 lg/kg) were given. We determined heart rate (HR), beat- measured by real-time PCR with genomic DNA purified from blood by-beat blood pressure (BP), HR-variability (HRV), and BP-variability (BPV). samples. Data were analyzed by stepwise backward logistic regression Supine BP and HR were similar in both groups. Before clonidine infusion, analysis. phenylephrine elicited a similar pressor response in both groups. Results The mean age of the cohort was 57.9 ± 9.8 years and mean Results Baroreflex loading with phenylephrine increased mean RR 24 hours blood pressures were systolic 125 ± 14.7 mmHg and dia- interval to a maximum of 1109 ± 60 msec in younger and stolic 73.9 ± 9.5 mmHg. Myocardial infarction and left ventricular 1163 ± 67 msec in middle-aged subjects (ns). Pharmacological barore- hypertrophy was present in 53.7%, and 47.2%, respectively. Telomere flex curves were similar in both groups. Baroreflex loading augmented lengths were significantly correlated with the thickness of the inter- HRV in both groups. The response was less pronounced in older sub- ventricular septum (IVST), and the left ventricular mass index (LVMI) jects. With clonidine infusion, the decrease in BP and HR was similar in (P < 0.05). As statistical effect size, a doubling of telomere length was both groups. The maximal change in systolic BP with phenylephrine associated with an increase of these cardiac parameters by 1.8% and after clonidine infusion was 17 ± 2 mmHg in younger and 2.5%, respectively. Hereby, age emerged as significant covariate 28 ± 3 mmHg in older subjects (P < 0.05). Baroreflex loading with (P < 0.01). phenylephrine during clonidine increased mean RR interval to a maxi- Conclusion Telomere lengths are significantly associated with distinct mum of 1357 ± 55 msec in younger and 1196 ± 50 msec in older sub- parameters of cardiac structure. The influence is subtle in well con- jects (P < 0.05). trolled patients under guidelines directed antihypertensive therapy. Conclusion The shift of the baroreflex heart rate curve during cloni- The prognostic relevance, e.g. for the development of heart failure, dine infusion to lower blood pressure and heart rate values was much needs to be tested in prospective follow-up analysis. more pronounced in younger subjects. Baroreflex loading during clonidine greatly increased heart rate variability in younger subjects and to a lesser degree in older subjects (P < 0.05). We conclude that baroreflex loading during alpha-2 adrenoreceptor stimulation unmasks impaired parasympathetic heart rate reserve in middle-aged, but other- wise healthy subjects. The finding is consistent with a structural cause of the age-associated decline in parasympathetic heart rate control.

10 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

20 THROMBIN INDUCES EXPRESSION OF FUNCTIONALLY ACTIVE P2Y12 ADP RECEPTOR IN HUMAN VASCULAR SMOOTH MUSCLE CELLS B. H. Rauch1, S. Ermler1,A.Bo¨hm1, A. C. Rosenkranz1, J. Driessen1, J. A. Jakubowski2, A. Sugidachi3 and K. Schro¨r1 1Universita¨tsklinikum Du¨sseldorf, Pharmakologie und Klinische Pharmakologie, Universita¨tsstr. 1, 40225 Du¨sseldorf, Germany, 2Eli Lilly and Company, Indianapolis, IN, USA, 3Daiichi Sankyo Co., Tokyo, Japan

Introduction The platelet ADP receptor P2Y12 contributes to activation of platelets upon vascular injury and is the molecular target of the thi- enopyridine anti-platelet drugs. The present study describes that thrombin induces the transcription of P2Y12 in cultured human vascular smooth muscle cells (SMC). The functional consequences of increased

P2Y12 expression involve an enhanced mitogenic and inflammatory response to thrombin in human SMC.

Methods and Materials P2Y12 was determined by RT-PCR/qPCR, Wes- tern blotting, flow cytometry, and chromatin immunoprecipitation (ChIP) in cultured human saphenous vein and aortic SMC. Immunohis- tochemistry was performed in human carotis plaques. DNA synthesis was assayed by [3H]-thymidine incorporation, interleukin-6 (IL-6) expression by qPCR. Results Thrombin (3 U/ml) stimulated an up to 3-fold transcription of

P2Y12 mRNA. Total protein and cell surface expression of P2Y12 were also markedly increased within 6 hours after thrombin addition and this was sustained over 24 hours. Thrombin-induced transcription of

P2Y12 was dependent on activation of NFjB as was determined by Chip assay and by the use of a specific NFjB activation inhibitor. The P2Y receptor agonist 2-methyl-thio-ADP (MeS-ADP; 1 lM) did not affect basal mitogenesis. However, after 6 hour preincubation with thrombin addition of MeS-ADP resulted in a significantly enhanced mitogenesis compared to thrombin alone. This increased mitogenic response to thrombin was prevented by the active metabolite of prasugrel (R-

138727) suggesting that this effect was P2Y12-mediated. Furthermore, MeS-ADP enhanced expression of IL-6 mRNA P2Y12-dependently in human SMC after pretreatment with thrombin. In human carotid artery plaques, P2Y12 immunostaining was positive and co-localized with smooth muscle actin and with tissue factor, the rate-controlling step in thrombin generation. Conclusion In conclusion, thrombin increases transcription of the

P2Y12 receptor in human SMC. P2Y12 not only mediates ADP signaling in platelets but may be involved in an enhanced mitogenic and inflammatory response in the vessel wall under conditions of enhanced endogenous thrombin formation, such as acute coronary syndromes.

2009 The Authors 11 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

DRUGS IN ONCOLOGY

21 22 ERBITUX IN COMBINATION WITH SIGNIFICANCE OF DRUG TRANSPORTERS FOR CHEMOTHERAPY IN METASTATIC THE SYNERGISM OF FOLFOX CHEMOTHERAPY COLORECTAL CANCER (MCRC): D. Theile, S. Grebhardt, W. E. Haefeli and J. Weiss INDIVIDUALIZATION INCREASES PATIENT Department of Internal Medicine VI, Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld BENEFIT 410, 69120 Heidelberg, Germany C. Lu¨pfert1, A. Johne1, C. Stroh2, I. Celik3, B. Brockhaus1, 4 5 1 S. Liehr , B. Destenaves and A. Kovar Introduction FOLFOX is a cytostatic drug combination for adjuvant 1 Merck KGaA, Exploratory Medicine, Frankfurter Strasse 250, 64293 treatment of colorectal cancer (CRC) consisting of folinic acid, 5-fluoro- 2 Darmstadt, Merck KGaA, MS-ROB-Biomarker Discovery 2, Frankfurter uracil (5-FU), and oxaliplatin. The mode of synergistic interaction Strasse 250, 64293 Darmstadt, 3Merck KGaA, MS-RSO-Clin. BM Dev., between these compounds is not well investigated and little is known Frankfurter Strasse 250, 64293 Darmstadt, 4Merck Grafing, MS-RDD- concerning the role of drug transporters for the efficacy of FOLFOX Bioanalytics 3, Am Feld 32, 85567 Grafing, Germany 5Merck Serono therapy and the impact of oxaliplatin metabolite oxalate. S.A. - Geneva, Exploratory Medicine, 9, chemin des Mines, 1202 Geneva, Methods and Materials We therefore investigated the influence of Switzerland FOLFOX-components on drug transporter expression by quantitative real-time polymerase chain reaction and on the efficacy of each FOL- Introduction Cetuximab (Erbitux) is a chimeric monoclonal antibody FOX component by proliferation assay in the CRC model cell line approved in several oncological indications. This targeted agent has LS180. Control experiments with transporter over-expressing cell lines shown superior efficacy in mCRC, both in combination with irinotecan- were used to assess the significance of important transporters for the based and oxaliplatin-based chemotherapy. The benefit for the patient cytostatic activity of FOLFOX components. Median effect analysis was is even further increased via individualization of therapy. The example carried out to objectify the mode of oxalate’s contribution to oxalipla- of a randomized phase II study combining Erbitux with the FOLFOX-4 tin’s action. (oxaliplatin, leukovorin, fluorouracil) regimen is further analysed here. Results 72 h preincubation with 5-FU led to a significant sensitisation Methods and Materials The open-label, multicenter phase II study of LS180 cells towards oxaliplatin. Concurrently ATP7B, a known efflux had intention-to-treat (ITT) populations of 168 subjects in the FOLFOX- transporter of platinum (Pt) drugs, was down-regulated by 50% and 4 arm, and 169 subjects in the arm combining FOLFOX-4 with the Ce- several multidrug resistance-associated proteins (MRPs) were induced tuximab standard regimen. Cetuximab peak concentration was deter- (2--5-fold). Combination index analysis revealed that overexpression of mined in week 1, and trough concentrations were obtained in week 7 MRPs leads to synergistic effects of oxalate and its carrier diaminocy- and 20. They were measured using a validated enzyme-linked immuno- clohexane-Pt and might therefore be a beneficial factor for the efficacy sorbent assay. The KRAS mutation status of tumors was retrospectively of oxaliplatin containing cancer therapy. In addition, this study investigated using a quantitative PCR-based assay on DNA isolated revealed that MRP overexpressing cells contain less glutathione than from archived tumor material. Pharmacokinetics was investigated ver- the corresponding parental cell line and that glutathione content sus biomarker data using statistical and population pharmacokinetic clearly correlates with the IC50 of diaminocyclohexane-Pt. approaches. Progression-free survival was estimated using the Kaplan- Conclusion In conclusion, our results indicate a new mechanism of Meyer methods. FOLFOX chemotherapy synergism including reciprocal down- and up- Results The study showed that stratification by KRAS mutational status regulations of transport proteins both favouring synergistic drug had a positive impact on the overall response rate for treatment with effects in FOLFOX chemotherapy. Additionally, oxalate was demon- Erbitux (odds ratio 2.54, P = 0.011; Bokemeyer et al. JCO 2009; 5 663-- strated to be a pharmacologically relevant metabolite of oxaliplatin. 71). Results of the association between stratified biomarkers and pharmacokinetics will be presented. Conclusion KRAS is a valuable predictive marker, guiding the individualized treatment with Erbitux in mCRC.

12 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

23 24 PHARMACOKINETICS AND TOXICITY PROFILE EVALUATION OF THE PHYSIOLOGY-BASED OF BENDAMUSTINE IN PATIENTS WITH PHARMACOKINETIC (PBPK) MODEL PK-SIM ADVANCED HEPATOCELLULAR CARCINOMA IN CHILDREN RECEIVING HIGH-DOSE J. Teichert1, A. Athmani2, M. Dollinger3, S. Preiss1, METHOTREXATE 2 3 3 1 K. Schoppmeyer , P. Thermann , A. Zipprich and R. Preiss K. Adam1, S. Schmiedl1,2, J. Szymanski1,2, T. Imschweiler3, 1 Universita¨t Leipzig, Institut fu¨r Klinische Pharmakologie, Ha¨rtelstr. 16-18, S. Voelpel3, T. Niehues3, K. Sinha4, S. Wirth4, A. Abu Hejleh5, 2 04107 Leipzig, Universita¨tsklinikum Leipzig Ao¨R, Medizinische Klinik und P. Samayoa6, S. Willmann6, J. Lippert6 and P. A. Thu¨rmann1,2 3 Poliklinik II, Liebigstr. 20, 04103 Leipzig, Universita¨tsklinikum Halle 1Chair of Clinical Pharmacology, University Witten/Herdecke, Witten, (Saale), Universita¨tsklinik und Poliklinik fu¨r Innere Medizin I, 2HELIOS Clinic Wuppertal, Philipp-Klee Institute of Clinical Pharmacology, Ernst-Grube-Str. 40, 06120 Halle, Germany Heusnerstrasse 40, D-42283 Wuppertal, 3HELIOS Clinic Krefeld, Children’s Hospital, Krefeld, 4HELIOS Clinic Wuppertal, Children’s Hospital, Introduction In a phase II study evaluating the clinical activity of ben- Wuppertal, 5HELIOS Clinic Krefeld, Institute for Hygiene and Laboratory damustine (B) in 13 Child-Pugh A and B class patients (11 male/2 Medicine, Krefeld, 6Bayer Technology Services GmbH, Competence Center female) with advanced hepatocellular carcinoma (HCC), some of them Systems Biology, Leverkusen, Germany pretreated with sorafenib, the pharmacokinetics of B and its metabolites and the B-related toxicity have been investigated. Introduction Administration of high-dose methotrexate (HD-MTX) in Methods and Materials In HCC patients, CT and MRI technique revealed children is a high-risk procedure due to concentration-related MTX tox- moderate or strong tumor involvement of the liver and the mean levels of icity. Physiology-based pharmacokinetic (PBPK) models are used in GGT and SGOT were elevated 10-fold and those of bilirubin 2.5-fold com- drug development for predicting drug serum levels in humans but a pared to the reference group. Reference group included 12 patients (5 m/ systematic evaluation of its applicability in a clinical setting is missing. 7 f) with various tumor types of non-hepatic origin resistant to all other Therefore, we want to evaluate PK-SIM -- a generic PBPK modelling therapies. All the subjects in both groups had normal renal function. B 2 and simulation tool -- in children receiving HD-MTX. hydrochloride 120 mg/m was given intravenously, daily for 2 consecutive Methods and Materials In two hospitals we included children receiv- days. Plasma concentrations of B and its metabolites were determined ing HD-MTX and used their routine methotrexate serum levels (MTX- using a validated HPLC assay with fluorescence detection. Toxicity was SL) for further analysis. Patients were grouped by age and relevant scored over 4 weeks according to NIH/NCI criteria. data (e.g. co-morbidities) were documented. PK-SIM will be evaluated Results B clearance tended to decrease in HCC (mean values: 639 ver- in two steps. Using published PK data and one half of our patients in sus 304 ml/min, non-significantly). Mean terminal half-life of B was sig- each age group, PBPK simulation will be optimized to match MTX-SL. nificantly prolonged in subjects with hepatic impairment (47 versus The actual evaluation will be done by comparing predicted and 33 min. P < 0.01), but the volume of distribution remained unaltered. observed MTX-SL in the second half of our patients. Relevant data (e.g. The elimination half-life and AUC were significantly increased inf co-medication) will be analyzed in a descriptive manner. (P < 0.01) for the monohydrolysis product of B in HCC patients. The Results We included 29 patients aged 2 to 18 years with 364 MTX-SL who pharmacokinetic parameters of both phase I metabolites (gamma- received MTX i.v. (n = 2) or i.v. and i.th. (n = 27). Age groups (2 to 5; 6 to hydroxy B and N-desmethyl B) remained unaltered. Performing a semi- 12 and 13 to 18 years) include 15, 5 and 9 patients, respectively. We quantitative scoring, enhanced B-induced toxicity was found in HCC. revealed a wide inter- and intra-patient variability of MTX-SL in children Sustained leukopenia, lymphocytopenia, and thrombocytopenia also receiving comparable MTX doses. Development of an intrathecal MTX- developed more frequently in those patients compared to the refer- model and PK-SIM evaluation is ongoing. ence group. Conclusion Evaluation of PBPK-model in pediatric patients receiving Conclusion Based on these data, we would suggest a stepwise dose HD-MTX might be a promising approach for predicting MTX-SL. Pro- reduction up to 30--40% in subjects with moderately to strongly spective clinical studies are required to quantify clinical practicability impaired liver function related to serum total bilirubin levels in the and benefit. range from 1.3 to 3.0 mg/dl.

2009 The Authors 13 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

25 26

SAFE COADMINISTRATION OF THE NK1 CARDIOVASCULAR EVENTS IN CLINICAL RECEPTOR ANTAGONIST APREPITANT AFTER TRIALS IN PATIENTS WITH MULTIPLE HIGH-DOSE MELPHALAN CHEMOTHERAPY: MYELOMA -- SUSAR OR NATURAL COURSE OF RESULTS FROM A RANDOMIZED DISEASE? PLAZEBO-CONTROLLED STUDY IN PATIENTS C. Schindler1, J. Siegert1,2, U. Gra¨fe1, A. Boehme2 and W. Kirch1,2 WITH MULTIPLE MYELOMA 1 TU Dresden, Institut fu¨r Klinische Pharmakologie, Fiedlerstrasse 27, 01307 K. Eisenlohr1, G. Egerer2, M. Gronkowski2, J. Burhenne1, Dresden, 2TU Dresden, Ethikkommission, Fiedlerstrasse 27, 01307 Dresden, K.-D. Riedel1 and G. Mikus1 Germany 1Department of Internal Medicine VI, Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld Introduction In clinical trials investigators and drug safety departments 410, 69120 Heidelberg, 2Department of Internal Medicine V, Hematology, have to distinguish between complications of the basic disease Oncology and Rheumatology, University of Heidelberg, Im Neuenheimer (events) and adverse drug reactions due to the therapy of the disease. Feld 410, 69120 Heidelberg, Germany Furthermore it has to be distinguished between expected (e.g. listed in investigators brochures or previous SUSAR reports) and unexpected Introduction High-dose melphalan chemotherapy is commonly used reactions (which might be reported as SUSAR). as conditioning therapy before blood stem cell transplantation in mul- Methods and Materials According to the legal requirements physi- 2 tiple myeloma. High-dose melphalan (100 mg/m , day 1 and 2) is asso- cians treating patients within clinical trials have to inform the sponsor ciated with severe acute and delayed emesis. To improve nausea and of the corresponding trial immediately concerning all serious adverse vomiting in these patients aprepitant was added to the standard antie- events (SAE) that occur during the trial. Thereafter the sponsor has to metic regimen and compared to the goldstandard in a placebo con- inform the competent authorities and concerned ethics committees trolled study. The aim of this investigation was to assess the effect of (EC) within 7 or 15 days about all suspected unsuspected serious aprepitant on the pharmacokinetics of high-dose melphalan. adverse reactions (SUSAR). Thereby the sponsor needs to monitor and Methods and Materials Thirty patients were included in this study. to evaluate the incoming SAE to extract the SUSAR to be reported to Aprepitant (125 mg) or placebo were administered 1 hr before melpha- authorities and EC. 2 lan therapy (1 hr infusion of 100 mg/m ). Eleven plasma samples were Well established and rather typical cardiovascular complications in mul- obtained over 8 hours and melphalan was quantified using an LC/MS/ tiple myeloma patients are hyperviscosity of blood (embolism and MS method. Standard pharmacokinetic parameters were calculated stroke), thrombopenia (bleeding complications) and amyloidosis (car- using WinNonlin 5.2 (Pharsight). The t-test was applied to assess the diomegaly, arrhythmias). differences between aprepitant and placebo treatment. Results During a short time period (approx. 1 month) for two clinical Results Twenty patients received placebo and 10 patients aprepitant trials (immunmodulator and proteasomen inhibitor) treating multiple treatment. There were no differences observed for Cmax at the end of myeloma eight cardiovascular SUSAR were reported as unexpected reac- melphalan infusion (placebo: 3431 ± 608 ng/ml versus aprepitant: tions. These cases included sudden cardiac death, cardiac arrest, three 3269 ± 660 ng/ml). In addition, AUC and terminal elimination half-life cases of tachycardia/arrhythmia, cardiac infarction, collapse and dyspnoe were not changed by aprepitant. Total clearance of melphalan was due to pulmonary embolism, prolonged QTc and cardiomyopathia. 2 304 ± 58 ml/min/m (placebo) which was not influenced by aprepitant Conclusion Due to the fact that all these reactions might be explained 2 (288 ± 78 ml/min/m ). as complications of multiple myeloma (events) and thereby have not Conclusion The administration of the NK1 receptor antagonist aprepit- to be classified as unexpected the appropriateness of the expedited ant 1 hr before a high-dose chemotherapy does not influence the SUSAR reporting for these medical conditions should be questioned. exposure and the elimination of melphalan. Therefore, no pharmacoki- According to earlier independent observations1 at least 85% of the SU- netic interaction between aprepitant and melphalan occurs and the SAR reports sent to ethics committees do not fulfill the legal defini- combination can safely be administered. tions given for expedited SUSAR reporting. Reference 1. S. Trillenberg, et al. Analysis of SUSAR reports sent to an Ethics Com- mittee, P 9, 10. VKliPha Congress, Berlin, 2008.

14 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

27 28 INVOLVEMENT OF THE MICRORNA LET-7 IN CONVECTION-ENHANCED DELIVERY OF THE REGULATION OF PROGESTERONE NON-PEGYLATED LIPOSOMES OF TOPOTECAN RECEPTOR MEMBRANE COMPONENT 1 AND GADODIAMIDE IN MALIGNANT GLIOMA EXPRESSION IN OVARIAN CANCER CELLS M. Luz1,2, A. Y. Grahn1, M. Dugich-Djordjevic3, J. R. Bringas4, 4 1 5 4 A. Wendler1, J. J. Peluso2 and M. Wehling1 P. Hadaczek , G. A. Johnson , S. Eastman and K. S. Bankiewicz 1 1Universita¨t Heidelberg, Klinische Pharmakologie Mannheim, Maybachstr. MedGenesis Therapeutix Inc., 730-730 View Street, Victoria V8W 3Y7, 2 14, 68169 Mannheim, Germany, 2Health Center, Department of Cell Canada, MedGenesis Therapeutix Inc., Goeggstr. 17, 68199 Mannheim, 3 Biology, University of Connecticut, 263 Farmington Ave, Connecticut Germany, Neurocore, 12966 Caminito Bautizo, San Diego, CA 92130, 4 06030, USA USA, Department of Neurological Surgery, University of California San Francisco, 1855 Folsom Street, San Francisco, CA 94103, USA, 5Northern Introduction Progesterone receptor membrane component 1 Lipids Inc., Formulation Development, 8855 Northbrook Court, Burnaby (PGRMC1) is part of a multi-protein complex that binds progesterone BC V5J 5J1, Canada and mediates nongenomic actions of this steroid. The protein is induced in different cancers, where it promotes cell survival and che- Introduction Convection-enhanced delivery (CED) is a local drug deliv- motherapy resistance. We analyzed the involvement of microRNAs ery technique that uses bulk flow for drug distribution and holds (miRNAs) in the expression regulation of PGRMC1. promise for the treatment of malignant glioma [1,2]. Methods and Materials Using TargetScan, microRNA.org, and miRDB Methods and Materials We developed CED-compatible, non-PEGylat- several miRNA binding sites in the 3¢-untranslated region (UTR) of ed liposomal formulations of topoisomerase I-inhibitor topotecan (to- PGRMC1 were predicted. The miRNA let-7 is a promising candidate as poCED) and paramagnetic gadodiamide (gadoCED), and studied its downregulation correlates with chemotherapy-resistance in ovarian them in CED models of naı¨ve and tumor-implanted rats. cancer cells1. To validate the miRNA binding sites of let-7, luciferase Results TopoCED had a half-life in brain of approximately one day, and activity was measured in an ovarian cancer cell line transfected with at 10 lg (0.5 lg/ll) increased the area under the concentration-time constructs containing the complete 3¢-UTR of PGRMC1 or the 3¢-UTR curve (AUC) 28-fold versus free topotecan (153.8 versus 5.5 lg day/g). lacking the let-7 binding sites downstream the luciferase gene. Addi- When infused together, topoCED and gadoCED co-convected well both tionally, cells were cotransfected with a let-7 mimic or inhibitor. in naı¨ve rat brain and malignant glioma xenografts (correlation coeffi- Results Luciferase activity in cells transfected with a construct contain- cients 0.97--0.99). In a U87MG cell assay, the 50% inhibitory concentration ing the 3¢-UTR of PGRMC1 downstream the luciferase gene (luc-3¢-UTR) (IC50) of topoCED was approximately 0.8 lM at 48 and 72 hours; its con- was lower than in cells transfected with the pure luciferase vector. Co- centration-time curves were similar to free topotecan and unaffected by transfection of luc-3¢-UTR and a let-7 mimic resulted in an even lower gadoCED. In the U87MG intracranial rat xenograft model, a two-dose reg- luciferase activity. This was due to binding of the let-7 mimic to let-7 imen of topoCED co-infused with gadoCED (20 ll over 40 min on days 5 binding sites in the 3¢-UTR of PGRMC1, as the activity was recovered and 8 post inoculation) increased median overall survival at concentra- when the let-7 binding sites were deleted. tions of 0.5 lg/ll (29.5 days) and 1.0 lg/ll (33.0 days) versus control Conclusion The data show that PGRMC1 is targeted by let-7. There (20.0 days; P < 0.0001 for both comparisons). TopoCED at higher con- may be a correlation between let-7 downregulation, PGRMC1 upregula- centrations (1.6 lg/ll) co-infused with gadoCED (1.15 lg/ll) showed no tion and chemotherapy resistance in cancer cells. In the future miRNAs evidence of histopathologic changes attributable to either agent. like let-7 targeting PGRMC1 possibly may be used to develop a more Conclusion The positive results of tissue pharmacokinetics, co-convec- efficient chemotherapy. tion, cytotoxicity, efficacy, and lack of toxicity of topoCED in a clinically Reference meaningful dose range, combined with an ideal matched-liposome 1. Yang et al. Cancer Res. 2008; 68: 10307--14. paramagnetic agent, gadoCED, implicate further clinical applications of this therapy in the treatment of malignant glioma. References 1. Fiandaca et al. Neurotherapeutics 2008; 5: 123--127. 2. Bidros and Vogelbaum. Neurotherapeutics 2009; 6: 539--546.

2009 The Authors 15 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

DRUG THERAPY IN ELDERLY PATIENTS

29 30 PHARMACOKINETICS, PHARMACODYNAMICS EVALUATION OF QUALITY AND AND THE AGING KIDNEY APPROPRIATENESS OF PAIN MEDICATION IN 1 2 F. Keller and D. Czock NURSING HOME RESIDENTS: A PILOT STUDY 1Universita¨tsklinikum, Klinik Innere Medizin 1, Nephrologie, Albert Einstein Allee 23, D-89070 Ulm, 2Department of Internal Medicine VI, Clinical IN GERMANY ¨ 1 2 2 1 ¨ 2 Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im M. Kolzsch , K. Kopke , T. Fischer , J. Bolbrinker , D. Drager and R. Kreutz1 Neuenheimer Feld 410, 69120 Heidelberg, Germany 1Charite´ - Universita¨tsmedizin Berlin, Institut fu¨r Klinische Pharmakologie und Toxikologie, Charite´platz 1, 10117 Berlin, Introduction In people aged 65 years and older, pharmacokinetics is 2 influenced more by the loss of kidney function than by the aging pro- Charite´ - Universita¨tsmedizin Berlin, Institut fu¨r Medizinische Soziologie, cess of any other organ. A glomerular filtration rate (GFR) of 30--60 ml/ Charite´platz 1, 10117 Berlin, Germany min, suggestive of stage 3 kidney disease, is observed in 15--30% of elderly people, which may require drug dose adjustments. However, Introduction Our aim was to test a tool for evaluation of pain the extent of pure age-related changes in pharmacokinetics is unclear. medication and prove its applicability regarding appropriateness of Methods and Materials Using our NEPharm database, where we pain control in nursing home residents (NHR) in Germany. record pharmacokinetic parameters since 1999 from a weekly PubMed Methods and Materials The ‘Pain medication appropriateness scale’ search, we identified and compared pharmacokinetic parameters from (PMAS) was developed in 2006 in the US. We translated the scale young and elderly subjects (>65 years). according to a standardized method und conducted a pilot study to Results Purely age-related changes in pharmacokinetic parameters test the scale in NHR. In this scale pain control is classified in a per- were recorded from publications on 127 drugs. The analysis revealed centage scale in which a score <67% indicates poor pain control. an average age-related prolongation of half-life of only +23% corre- Data on all medication prescribed to the subjects, pain intensity, sponding to a 1.23-fold increase (range 0.91--1.45). A median decrease and surgery procedures or injuries during the last 3 weeks were col- of -1% (range -14 to +35%) was observed for the drug clearance and a lected. paradox +4% increase in the volume of distribution was found (range Results Overall, 51 residents were included, 47 of them suffered ±0 to +37%). The impact of pharmacokinetic alterations was consid- from pain at the moment of the interview. From these 33 (70%) ered clinically significant for carboplatin, chlorpropamide, digoxin, en- subjects had a prescription for permanent pain medication. For 38 oxaparin, gentamicin, lithium, metformin, methotrexate, nitrofurantoin, residents the PMAS could be applied, the mean value was 54%. and some drugs acting on the central nervous system. Nearly 60% of all subjects had a PMAS score lower than 60%. Due Conclusion The limited extend of pharmacokinetic changes in elderly to mental status, 28 subjects (74%) were able to evaluate the pain subjects does not suggest general dose modifications. The modest relief achieved by the prescribed pain medication. No pain relief increase in half-life can be explained by the dependence of the drug was stated by 1(3%) subject, 11 (29%) residents declared little pain half-life on GFR according to a hyperbolic function. relief, and seven (18%) enough relief, while no subject declared full relief of pain. Conclusion Our experience in this small pilot study demonstrates that the PMAS tool is useful for the evaluation of pain control in German NHR. The preliminary data indicate that in more than half of the patients pain control by pharmacotherapy is poor.

16 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

31 32 MEDICATION AND FALLS IN OLDER HOSPITAL IMPACT OF DRUG INTERACTIONS ON THE INPATIENTS -- A CASE--CONTROL STUDY RISK OF HIP FRACTURE ASSOCIATED WITH K. Peters, M. K. Modreker, S. Golgert, T. Krause and BENZODIAZEPINE USE W. von Renteln-Kruse K. Zint1,2, W. E. Haefeli1, R. J. Glynn2, H. Mogun2, J. Avorn2 and Geriatric Clinic, Albertinen-Haus, Centre of Geriatrics and Geronotology, T. Stu¨rmer1,2,3 University of Hamburg, Sellhopsweg 18-22, 22459 Hamburg, Germany 1Department of Internal Medicine VI, Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany, Introduction The role of medication in contributing to increased fall- 2Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham risk, particularly in older patients, is equivocal. However, medication and Women’s Hospital, Harvard Medical School, Boston, 3Department of review is an essential part of multidimensional falls-prevention pro- Epidemiology, UNC Gillings School of Global Public Health University of grams. The aim was to study differences in patterns, doses and num- North Carolina at Chapel Hill, Chapel Hill, USA ber of drugs prescribed between older patients with and without in- hospital falls. Introduction Benzodiazepine use is associated with an increased risk Methods and Materials Hundred patients who fell (152 total falls; 67 of hip fracture in the elderly. Little is known about the impact of drug patients with single, 33 patients with ‡2 falls) were matched to 100 interactions on this association. We aimed to determine how concomi- patients without falls, according to age, gender, main diagnosis, and tant use of interacting drugs modifies the risk of hip fracture associ- level of functional competence (66 females, mean age 78.5 years, mean ated with benzodiazepine and benzodiazepine-related drug (zolpidem) total Barthel-Index score on admission 39.2 and 39.5, respectively). (BDZ) use. Total medication administered within the 24h interval before the first Methods and Materials We performed a nested case-control study (index) fall event in fallers and matched patients (same day of in-hospi- in Medicare patients 65 years or older, enrolled in the Pennsylvania tal stay) was recorded and compared (ATC code, daily dose, drug com- drug assistance program (PACE) between 1994 and 2005. 17 198 binations). patients with a hip fracture leading to hospitalization and 85 990 Results Drug exposure was high in both patient groups (8.3 ± 2.5 ver- controls matched on the month of hospitalization (index date) were sus 7.9 ± 2.9 medications). Antidepressants were prescribed more fre- included in the study. BDZ and interacting drug use within two quently to patients who fell, 32 versus 16 (P = 0.008), and there was a weeks preceding the index date was determined using information similar trend for anti-asthmatics (11 versus 4; P = 0.06) and neurolep- on service start date, days supplied, quantity dispensed, and tics (15 versus 7; P = 0.07). There were no significant differences strength prescribed. regarding the number of single drugs, combination of antihyperten- Results For overall BDZ use we found an adjusted risk ratio (RR) of 1.2 sives, sedatives/hypnotics, psychotropics, and deviations from defined (95% confidence interval (CI): 1.1--1.2). We observed increased risks for daily doses of antihypertensives, sedatives/hypnotics and antidepres- concomitant use of alprazolam, lorazepam, and zolpidem and their sants that were most frequently prescribed. interacting drugs with RRs of 1.5 (CI: 1.3--1.7), 1.9 (CI: 1.7--2.2), and 1.7 Conclusion The level of total drug exposure, prescribing pattern, dos- (CI: 1.4--2.0). However, only for alprazolam we found a tendency toward age and combination of drugs were not significantly associated with a a departure from additive risks with a proportion of disease among first fall event (index fall) in older hospital in-patients. Further studies those with both exposures that is attributable to their interaction of should focus on high-risk hospital inpatients with multiple falls. 13% (95% CI: 0 to 27%). M. K. Modreker is supported by a Forschungskolleg Geriatrie Grant Conclusion The risk of hip fracture is substantially higher in those from the Robert Bosch Foundation, Stuttgart, Germany. patients using concomitantly interacting drugs. Clinicians should avoid, whenever possible, concomitant use of BDZ and interacting drugs. Acknowledgements This study was funded by the Graduiertenkolleg 793 (German Research Foundation, DFG) and a grant (RO1 023178) from the National Institute on Aging of the National Institutes of Health.

2009 The Authors 17 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

33 34 ORTHOSTATIC HYPOTENSION (OH) IN PRESCRIBING PATTERNS OF PAIN GERIATRIC INPATIENTS -- PRECIPITATING MEDICATION TO ELDERLY NURSING HOME MEDICATION AND CLINICAL CONSEQUENCES RESIDENTS IN GERMANY M. K. Modreker, S. Golgert and W. von Renteln-Kruse M. Ko¨lzsch1, K. Kopke2, T. Fischer2, W. Hofmann2, J. Bolbrinker1, Geriatric Clinic, Albertinen-Haus, Centre of Geriatrics and Geronotology, D. Dra¨ger2 and R. Kreutz1 University of Hamburg, Sellhopsweg 18-22, 22459 Hamburg, Germany 1Charite´ - Universita¨tsmedizin Berlin, Institut fu¨r Klinische Pharmakologie und Toxikologie, Charite´platz 1, 10117 Berlin, Introduction The prevalence of orthostatic hypotension (OH) is 2Charite´ - Universita¨tsmedizin Berlin, Institut fu¨r Medizinische Soziologie, increasing with old age. Aim of the study was to screen for OH in geri- Charite´platz 1, 10117 Berlin, Germany atric inpatients and to evaluate underlying conditions and therapeutic consequences. Introduction Our aim was to evaluate prescribing patterns of pain Methods and Materials Consecutive patients were investigated by medication to elderly German nursing home residents (NHR) in relation standard procedure, medication review, and history of falls to documented diagnoses. (£3 months). Methods and Materials We conducted a retrospective cohort study Results There were 102 out of 232 patients (f = 67, m = 35; age with prescription data from a German health insurance company 80.2 ± 7.2 years.) with systolic (9), diastolic (35) or combined OH (Deutsche BKK) in NHR 65 years or older. The utilised dataset contained (n = 55) and POTS (postural orthostatic tachycardia syndrome) (3). date of prescription, date of dispensary, costs of the drug, quantity of Symptomatic OH was present in 74 patients (75%). The average num- dispensed packages, ATC -- Code, and indication. ber of drugs used was 8.3 ± 3.0, with ‡5 drugs in 93 patients (91%). Results Overall data from 8685 subjects were analysed, 7271 (84%) Drugs potentially precipitating OH were prescribed to 95 patients with were female, and 1414 (16%) were male. The average age was cardiovascular medication most frequently incriminated (21/25). Symp- 83.6 ± 7.3 years (men 80.3 ± 8 years, females 84.3 ± 6.9 years). tomatic OH was associated with a history of recent falls (P < 0.001). Coxarthrosis was diagnosed in 745 (9%) subjects, 48% of these had a Termination (14), adaptation of doses (11) and start of medication (6) prescription for non-opioid or opioid analgesics. The analysis of sub- was followed by clinical improvement in 18/74 (23%) patients. jects with the diagnosis ‘pain, not elsewhere classified’ (ICD-10: R 52) showed that nearly 25% of affected individuals received no prescrip- Table. Medication changes in 18 patients with symptomatic orthostatic tion on pain treatment at all. Only 20% of residents receiving morphine hypotension were prescribed lactulose simultaneously. Some subjects (2.3%) received inappropriate prescriptions of two opioids of WHO pain relief Medication Termination Dose-reduction Start Total ladder step two and three together. Conclusion Using coxarthrosis as an example and the fact that about Diuretics 4 6 1 11 50% of all subjects with coxarthrosis are known to suffer from pain we Opioides 3 1 0 4 consider the frequency of pain medication prescriptions for this condi- ACE-inhibitors 2 0 2 4 tion to be adequate in our cohort. We identified potential deficits in Beta-blockers 0 2 1 3 pain treatment relating to underuse of prescribed drugs in patients Moxonidin 2 0 0 2 Nitrates 2 0 0 2 with unclassified pain and in the combination therapy and use of co- Sedatives/hypnotics 0 0 2 2 medications during treatment with opioids. Sartanes 0 1 0 1 Benzodiazepines 0 1 0 1 Verapamil 1 0 0 1 Total 14 11 6 31

Conclusion OH was frequent in geriatric inpatients. Symptomatic OH was associated with a history of recent falls. Exclusion of orthostatic hypotension should be obligatory in older patients with a history of falls. Diuretics and cardiovascular drugs were most frequently incriminated with OH. Acknowledgements M.K. Modreker is supported by a Forschungskol- leg Geriatrie Grant from the Robert Bosch Foundation, Stuttgart, Germany.

18 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

35 36 DEVELOPMENT OF A GERMAN LIST OF INAPPROPRIATE MEDICATION PRESCRIBING POTENTIALLY INAPPROPRIATE MEDICATION FOR ELDERLY OUTPATIENTS IN SAXONY -- AN IN THE ELDERLY EVALUATION OF CLAIMS DATA S. Holt1,2, S. Schmiedl1,2 and P. A. Thu¨rmann1,2 M. Huber1,2, G. A. Kullak-Ublick2 and W. Kirch1 1HELIOS Klinikum Wuppertal, Philipp Klee-Institut fu¨r Klinische 1Technische Universita¨t Dresden, Institute of Clinical Pharmacology, Pharmakologie, Heusnerstraße 40, 42283 Wuppertal, 2Private Universita¨t Faculty of Medicine, Fiedlerstraße 27, 01307 Dresden, Germany 2University Witten/Herdecke gGmbH, Lehrstuhl fu¨r Klinische Pharmakologie, Alfred- Hospital Zurich, Division of Clinical Pharmacology and Toxicology, Herrhausen-Straße 50, 58448 Witten, Germany Department of Internal Medicine, Ra¨mistrasse 100, 8091 Zu¨rich, Switzerland Introduction Certain drugs are classified as potentially inappropriate medication (PIM) due to their increased risk for causing adverse drug Introduction In elderly patients, certain drugs are more often associ- reactions in elderly patients1. Since published international PIM lists ated with adverse effects than others, their use should be avoided may not be suitable for Germany, we are developing a German PIM list whenever possible1. for elderly patients (http://www.priscus.net, SP3). Methods and Materials We performed a retrospective analysis of drug Methods and Materials After analysing established PIM lists and prescription data in outpatient care, provided by a statutory health reviewing the literature, a preliminary German PIM list has been cre- insurance in Saxony for the years 2003 and 2004. Inappropriate pre- ated including more than 130 different drugs of 20 drug classes. A scribing was assessed using the 2002 Beers criteria1. The evaluation web-based, modified two round Delphi survey (RAND Corporation was restricted to those drugs which were inappropriate based on the 1969) with a German speaking expert panel has been performed using criteria without any restrictions regarding dosage or duration of appli- a 5-point Likert scale with regard to e.g. comorbidities. cation. Results Twenty-five experts of seven different specialties finished the Results A total of 12 513 584 prescriptions for patients 65 years and first round of the survey. Almost 50% of the drugs stated in the preli- older in 2003 and 10 126 809 in 2004 were evaluated. The majority of minary list as PIM for elderly patients, e.g. indomethacin. In contrast 17 prescriptions (67.9% and 67.1%) affected female individuals. 408 375 drugs were rated as suitable for elderly patients, e.g. tramadol. In 56 prescriptions in 2003 and 297 524 in 2004 involved an inappropriate drugs, experts’ rating failed to make a clear decision and these drugs drug from the Beers list, representing 3.3% and 2.9% of all drugs pre- will be re-assessed in the second round which will be finalized in sum- scribed (P < 0.001). In 2003, short-acting nifedipine was the inappropri- mer 2009. ate drug most often prescribed (13.4%), followed by indomethacin Conclusion Since there are complex clinical therapeutic needs and (12.3%) and diazepam (11.8%). In contrast, diazepam was in the first problems in elderly people, using a ‘yes-or-no’ scheme may oversim- place in 2004, accounting for 14.6% (indomethacin 13.7%, doxazosine plify drugs’ assessment in many instances. In the next step the final 10.9%). 119 482 patients 65 years and older received at least one inap- PIM list will be validated regarding the relationship between usage of propriate drug in 2003 (2004: 98,465), representing 21.7% (18.2%) of all PIM and the occurrence of clinically relevant adverse effects in several patients. cohorts of elderly German patients. Conclusion Since the Beers criteria were developed for the situation in Supported by BMBF Fo¨-Nr. 01ET0721 the United States, which is different from Europe, an adaption of the Reference list to the national level is necessary. The need to improve drug ther- 1. Fick DM et al. Arch Intern Med. 2003; 163: 2716--24. apy in older patients is essential, also in the light of the ongoing demographic change in Western countries, especially in Germany. Reference 1. Fick et al. Arch Intern Med 2003; 163: 2716--24.

2009 The Authors 19 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

PHARMACOKINETICS

37 38 PREDICTION OF PARTIAL METABOLIC PHARMACOKINETICS OF THE SOLVENT CLEARANCE OF MIDAZOLAM FROM PARTIAL SULFOBUTYLETHER-BETA-CYCLODEXTRIN AUC AS A MARKER OF CYP3A4 ACTIVITY (SBECD) IN PATIENTS WITH CHRONIC RENAL S. Katzenmaier, C. Markert and G. Mikus FAILURE DURING HAEMODIALYSIS Department of Internal Medicine VI, Clinical Pharmacology and TREATMENT WITH TWO SYSTEMS AND Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany HAEMODIAFILTRATION V. Hafner1, D. Czock1, J. Burhenne1, K.-D. Riedel1, J. Bommer2, 1 1 Introduction To determine the activity of CYP3A4 midazolam is often G. Mikus and W. E. Haefeli 1 used as a probe drug for this enzyme. The primary route of midazolam Department of Internal Medicine VI, Clinical Pharmacology and elimination is the 1-hydroxylation with subsequent conjugation Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld accounting for 60--70% of the dose. Several different limited sampling 410, 69120 Heidelberg, 2Dialysezentrum Heidelberg, Bergheimer Str. 59/61, strategies including single concentration measurements have been 69115 Heidelberg, Germany used in order to simplify sampling procedures and minimise costs. This study evaluates a new method to predict metabolic clearance and sub- Introduction Sulfobutylether-beta-cyclodextrin (SBECD) is used to solu- sequently CYP3A4 activity in an easy and reliable way. bilise voriconazole for intravenous administration. It is eliminated pri- Methods and Materials Twelve volunteers received 3 mg midazolam marily by renal excretion and accumulates in patients with renal p.o. alone, on the first day and on day 14 of an efavirenz treatment failure. However, the pharmacokinetics of SBECD in patients undergo- (400 mg p.o. once daily). An LC/MS/MS method was applied to deter- ing extracorporeal renal replacement therapies is still unclear. mine midazolam and 1-OH-midazolam concentrations in plasma and Methods and Materials We performed a three-period randomized urine (after hydrolysis) samples obtained from this induction study of cross-over study in patients with end-stage renal failure (n = 15) during CYP3A4. Partial metabolic clearance of midazolam was calculated as treatment with Genius dialysis (GD), standard hemodialysis (HD), or he- amount 1-OH-midazolam (after hydrolysis) excreted in urine divided by modiafiltration (HDF) using a standard high-flux polysulfone mem- midazolam AUC. Different partial AUCs of midazolam in plasma were brane. At the start of renal replacement therapy the patients received related to the partial metabolic clearance using nonlinear regression a single two-hour infusion of 4 mg per kg body weight voriconazole. (Graphpad Prism 5.03). SBECD concentrations were quantified in plasma, dialysate, and urine Results The highest R2-value (0.9816) was obtained for the relationship samples by HPLC/Fluorescence and analysed by noncompartmental between the partial AUC between 2 and 4 hours after oral administra- methods using WinNonlin 5.2. Nonparametric repeated measures ANO- tion of midazolam and the partial metabolic clearance. This partial AUC VA was used to analyse the differences between the treatments. comprises four midazolam concentrations at 2, 2.5, 3 and 4 hours. Pre- Results SBECD was effectively eliminated during 6 hours of renal dicted partial metabolic clearance and measured partial metabolic replacement therapy. The concentrations of SBECD declined with a clearance showed no significant difference (P = 0.1276, n = 36, Wilco- half-life ranging from 2.7 ± 0.7 hours (GD) to 2.4 ± 0.8 hours (HD) and xon test (Graphpad Instat 3). 2.1 ± 0.8 hours (HDF) (P < 0.01 for GD versus HDF). Conclusion This new limited sampling strategy predicts reliably the Conclusion SBECD was rapidly and extensively eliminated by all partial metabolic clearance of midazolam and thus CYP3A4 activity. applied renal replacement modalities using a high-flux polysulfone membrane. The SBECD half-life during HDF was nearly identical to the half-life of 1.8 hours observed in healthy individuals.

20 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

39 40 PLASMAKINETICS OF FENTANYL IN THE ANTICOAGULANT IDRAPARINUX: IS THE ORTHOTOPIC LTX EXTENSIVE HALF LIFE OF 60 DAYS THE CAUSE F. Baumann1, R. Regenthal1, U.-C. Pietsch2, F. Hokema2, OF BLEEDING COMPLICATIONS 2 1 U. Kaisers and R. Preiss J. Harenberg1, M. Wehling1, G. Mikus2 and C. Weiss3 1 Universita¨t Leipzig, Institut fu¨r Klinische Pharmakologie, Ha¨rtelstraße 1Ruprecht-Karls-Universita¨t Heidelberg, Clinical Pharmacology Mannheim, 2 16-18, 04107 Leipzig, Universita¨tsklinikum Leipzig, Klinik und Poliklinik Maybachstr. 14, 68169 Mannheim, 2Ruprecht-Karls-Universita¨t Heidelberg, fu¨r Anaesthesiologie und Intensivtherapie, Liebigstraße 20, 04103 Leipzig, Medical Faculty Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany 3Ruprecht-Karls-Universita¨t Heidelberg, Medical Faculty Mannheim, Institute for Biometrics and Statistics, Ludolf-Krehl-Str. 7-11, 68167 Introduction Liver transplantation is an established procedure for the Mannheim, Germany treatment of endstages of most different liver diseases and fentanyl is the opioid analgesic of choice in most liver transplantation centres Introduction Low-molecular weight heparins followed by vitamin-K because its pharmacodynamics is characterized by cardiovascular sta- antagonists have been shown to effectively prevent and treat venous bility, low histamine release, and an efficient analgesic effect. There are and arterial thromboembolism. Several major drawbacks of these anti- no data available on the pharmacokinetics of fentanyl during ortho- thrombotics induced the development of new anticoagulants. A modi- topic liver transplantation. fied polymethylated pentasaccharide, idraparinux, was developed for Methods and Materials We studied pharmacokinetics of fentanyl and once weekly subcutaneous application. We analysed the pharmacody- its main metabolite norfentanyl in 22 liver transplant recipients follow- namic properties of idraparinux in 23 patients at the end of a 6- or 12- ing two different application concepts. In concept A fentanyl was month therapy. infused until start of the unhepatic phase. Data were compared with Methods and Materials Plasma samples of patients, participating in those of concept B where fentanyl was continuously applied until rep- the van-Gogh trials for prevention of recurrent venous thromboembo- erfusion of the new liver. A sensitive LC-MS method with a liquid-liquid lism and receiving 2.5 mg idraparinux once weekly subcutaneously extraction was developed for the determination of fentanyl (LOQ were analyzed. At 3-month intervals for up to 15 months following the 0.2 ng/ml) and norfentanyl (LOQ 0.4 ng/ml) in human plasma termination of the therapy, the anti-factor Xa S2222 chromogenic sub- Results Concept B infusion regimen resulted in 90 percent higher strate (aXa) assay and Heptest were used to determine pharmacody- effective plasma fentanyl concentrations at the end of the anhepatic namic parameters. phase (mean Cmax 4.86 versus 2.53 ng/ml) and decreased with a con- Results The biological elimination half lives of idraparinux (t1/2) were text-sensitive half time of 0.67 h after reperfusion of the new organ. 60 days and 107 days (P < 0.0001) using the aXa assay and Heptest. Unbound free fractions of fentanyl showed no significant differences After 12 months of treatment (n = 18), maximum drug concentra- (7.9 versus 8.0%) between infusion concepts. tions and areas under the activity time curve were significantly Conclusion While both concepts were proofed to be clinically success- higher, volumes of distribution was lower and clearance, t1/2 and ful with target ranges of 1--3 ng/ml, concept A may be more adequate mean residence times remained unchanged compared to 6 months in terms of avoiding potential toxic effects of higher fentanyl concen- treatment (n = 5). trations and aspired in time postoperative extubation. This approach Conclusion The extremely long half life of idraparinux may explain the may result in an greater benefit for the clinical outcome of patients. severe bleeding complications during and after the clinical trials for prevention of recurrent venous thromboembolism and for prevention of systemic cerebral and non-cerebral embolism in atrial fibrillation. Biotinylated idraparinux is bound and eliminated by avidin and is currently being developed as antithrombotic.

2009 The Authors 21 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

41 42 DOSING ADJUSTMENT ACCORDING TO CASE REPORT: NON-SUFFICIENT DETTLI’S RULE: MEASURED CONCENTRATIONS OF OLANZAPINE IN A PHARMACOKINETICS IN KIDNEY PATIENTS PATIENT UNDER OLANZAPINE MELTING VERSUS URINARY RECOVERY IN HEALTHY TABLETS INDIVIDUALS A. Hader1 and E. Haen2 1 D. Czock1 and F. Keller2 Klinikum der Universita¨t Regensburg, Klinische Pharmakologie und 1Department of Internal Medicine VI, Clinical Pharmacology and Psychopharmakologie, Franz-Josef-Strauss-Allee 11/FoBau H3, 93053 2 Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld Regensburg, Klinikum der Universita¨t Regensburg, Klinische 410, 69120 Heidelberg, 2University Hospital Ulm, Division of Nephrology, Pharmakologie und Psychopharmakologie, Universita¨tsstr. 81, 93053 Albert Einstein Allee 23, 89070 Ulm, Germany Regensburg, Germany

Introduction A classical rule for dosing adjustments in renal insuffi- Introduction In our TDM laboratory (Therapeutic drug monitoring lab- ciency is Luzius Dettli’s proportional rule. With this rule the individual oratory) we routinely use two different reference ranges for the inter- elimination rate fraction (Q) is calculated by interpolation applying the pretation of measured concentrations: The therapeutic and the dose- elimination rate fraction in anuric patients (Q ). Dettli used measured related reference range; results are returned to the treating physician 0 1 elimination rate constants in anuric patients and healthy individuals to together with a clinical pharmacological comment . Methods and Materials Since August 2008 we continuously measured calculate Q0 as Q0 =ke,anur/ke,norm. When the elimination rate constant serum concentrations of a male patient, born in 1972, treated with ola- in anuric patients is unknown, Q0 can be predicted based on the uri- nzapine (45--60 mg per day) in a fast melting preparation who suffers nary recovery in healthy individuals (UR)asQ0,predicted = 1-UR. However, from hebephrenic schizophrenia. We found considerably low serum the accuracy of Q0,predicted is unknown. Methods and Materials Pharmacokinetic parameters for 60 antibiotics concentrations, too low in relation to the dosage prescribed (expected were extracted from 580 original articles of the scientific literature and between 39 and 143 ng/ml, measured concentrations between 12 and entered into the database PKnephro. When more than one value was 27 ng/ml) and explained this by the heavy smoking of the patient. Smoking induces the cytochrome P450 isoenzyme 1A2 which is the found for a parameter, the pooled mean was calculated. Then, Q0 was calculated based on these parameters using various methods and com- main metabolic pathway of olanzapine. Other reasons like non-compli- pared by statistical methods (Wilcoxon signed-rank test). ance could be excluded because the patient is at a forensic ward and Results Sufficient pharmacokinetic data was found for 34 antibiotics. gets his medication under control. After monitoring these low concentrations for several months we suggested to prescribe olanzapine as a Q0,predicted was significantly higher compared to Q0 (median 0.38 versus regular tablet. 0.2; P < 0.0001). The ratio Q0,predicted/Q0 was 1.84 (min--max 0.56--6.43). Additional analyses applying the ratio of renal and systemic drug clear- Results Five days after switching the galenics the measured olanzapine ance led to very similar results. concentration was appropriate in relation to the given dose (60 mg per day, expected concentration between 52 and 143 ng/ml, measured Conclusion Predicted Q0 values based on urinary recovery from concentration 93 ng/ml). healthy subjects systematically overestimate Q0 values based on measured elimination rate constants in patients with renal failure. There- Conclusion We suspect now that this patient is not able to absorb olanzapine from the melting tablets sufficiently. The reason for this fore, Q0 should not be predicted, but pharmacokinetic measurements in functionally anuric patients should be performed for all drugs. reduced bioavailability has to be further investigated. Reference 1. Haen E, Greiner C, Bader W, Wittmann M (2008): Wirkstoffkonzentra- tions-bestimmungen zur Therapieleitung - Erga¨nzung therapeuti- scher Referenzbereiche durch dosisbezogene Referenzbereiche. Der Nervenarzt 79, 558--566.

22 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

DRUGÀDRUG INTERACTIONS

43 44 REPEATED HONEY CONSUMPTION DOES NOT PHARMACOKINETICS AND SAFETY OF CHANGE CYP3A4 ACTIVITY IN HUMANS COMBINED ADMINISTRATION OF PRILOCAINE L. Fetzner, C.-H. Chung, J. Burhenne, W. E. Haefeli and G. Mikus AND ROPIVACAINE IN BRACHIAL PLEXUS Department of Internal Medicine VI, Clinical Pharmacology and ANAESTHESIA Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld G. Huschak1,H.Ru¨ffert1, M. Wehner1, M. Taubert1, 410, 69120 Heidelberg, Germany C.-D. Meinecke1, U. X. Kaisers1, R. Preiss2 and R. Regenthal2 1Universita¨t Leipzig, Klinik und Poliklinik fu¨r Anaesthesiologie und Introduction Not only drugs but also natural products have the poten- Intensivtherapie, Liebigstrasse 20, 04103 Leipzig, 2Universita¨t Leipzig, tial to modulate the metabolism and pharmacokinetics of xenobiotics/ Institut fu¨r Klinische Pharmakologie, Ha¨rtelstrasse 16-18, 04107 Leipzig, drugs. Food-drug and herb-drug interactions occur with a number of them have been reported. Several studies investigating the interaction Germany of honey and drug-metabolizing enzymes suggest that honey does influence CYP3A mediated metabolism in mammals and humans, prob- Introduction The combined use of different local anaesthetics is ably by induction. We conducted this clinical trial to determine the intended to utilize the specific advantages (onset and duration of effect of repeated honey administration on human CYP3A4 enzyme effect) of each drug. Despite clinical use there are no sufficient data activity using midazolam as a marker substance. concerning the pharmacokinetics and clinical toxicity possibly associ- Methods and Materials This randomized, single-blind, parallel-group ated with drug plasma concentrations following combined prilocaine/ study was carried out with twenty healthy subjects. They were ran- ropivacaine administration. domly assigned to receive either honey (2 · 20 g/d) or artificial honey Methods and Materials Within an open label clinical study sixty surgi- (2 · 20 g/d) over a period of ten days. To determine intestinal and cal patients underwent single shot plexus blockade using a fixed com- hepatic CYP3A4 activity oral (4 mg) and intravenous (2 mg) midazolam bined dose regimen of 300 mg prilocaine/75 mg ropivacaine. Plasma was administered in a semi-simultaneous way before honey administra- concentrations of local anaesthetics were serially measured by gas tion, after the last honey administration, and 1 and 5 days thereafter. chromatography and data were analysed for relationship to central or Results At baseline after oral midazolam the partial metabolic clear- cardiovascular toxicity parameters. Combined plasma pharmacokinetics ance was not different between the groups (honey: 917.8 ± 234.6 ml/ of prilocaine and ropivacaine was calculated in 10 of 59 patients. min versus artificial honey: 973.5 ± 373.8 ml/min). At the end of honey Results Mean peak plasma concentrations were 1.51 lg/ml and administration no significant changes were observed, which was also 1.12 lg/ml for prilocaine and ropivacaine within 15 to 30 minutes or true 1 and 5 days later. After intravenous administration of midazolam 0.5 to 1 hour after combined administration with high inter-individual there were also no significant differences over time and between both variability, but well below known toxic threshold concentrations. This groups. Therefore, bioavailability was always in the range of 28 ± 5%. could be confirmed in an extrapolated construct of combined toxicity Conclusion Our results showed that neither honey nor artificial honey considering drug specific potencies and observed cmax values. No rele- in amounts usually consumed affected the intestinal and hepatic vant cardiovascular toxicity was observed in 58 patients in terms of CYP3A4 activity in healthy volunteers. Especially, no induction of this QRS changes, PQ interval prolongation, AV dissociation, extrasystoles important enzyme was observed. or sinus arrest and only one of 59 patients showed signs of myoclonus suspicious for intravascular injection. Conclusion The use of fixed combined dose regimen of prilocaine/ropivacaine (300/75 mg) in patients with single shot brachial plexus blockade can be regarded as safe. The high inter-individual variability of local anaesthetics peak plasma concentrations and the one case of clinical toxicity highlight the need of adequate monitoring.

2009 The Authors 23 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

45 46 EFFECTS OF STEADY-STATE ENOXACIN, A WARFARIN PHARMACODYNAMICS AND BROAD-SPECTRUM FLUOROQUINOLONE, ON PHARMACOKINETICS ARE NOT AFFECTED BY SINGLE-DOSE PHARMACOKINETICS OF THE SOLUBLE GUANYLATE CYCLASE ROFLUMILAST AND ROFLUMILAST N-OXIDE STIMULATOR RIOCIGUAT (BAY 63-2521) N. Nassr1, L. Gezim2, H. Andreas2, H. Rolf2, E. Martin3 R. Frey1,W.Mu¨ck1, N. Kirschbaum2, J. Kra¨tzschmar1 and and H. Markus1 G. Weimann1 1Nycomed, Exploratory Clinical Development, Byk-Gulden-Strasse 2, 78467 1Bayer Schering Pharma AG, Clinical Pharmacology, Aprather Weg 18a, Konstanz, 2Nycomed, Pharmacometrics and Pharmacokinetics, 42113 Wuppertal, 2Bayer Schering Pharma AG, Global Biostatistics, Byk-Gulden-Strasse 2, 78467 Konstanz, 3Nycomed, Biomarker Aprather Weg 18a, 42113 Wuppertal, Germany Development, Byk-Gulden-Strasse 2, 78467 Konstanz, Germany Introduction Pulmonary hypertension (PH) is a progressive and debili- Introduction The oral, selective phosphodiesterase 4 (PDE4) inhibitor tating condition with a high rate of mortality. Riociguat (BAY 63-2521) roflumilast is under investigation for the anti-inflammatory treatment is a new drug in development for PH that is well tolerated and has a of chronic obstructive pulmonary disease (COPD). Roflumilast is cataly- superior efficacy to nitric oxide in patients with PH. Treatment recom- sed by CYP1A2 and CYP3A4 to its major metabolite roflumilast N-oxide, mendations for PH are based on combination therapies that include through which >90% of its total PDE4 inhibitory activity (tPDE4i) is warfarin. The aim of this study was to investigate potential pharmaco- mediated in vivo. The fluoroquinolone antibiotic enoxacin is often used dynamic or pharmacokinetic interactions of riociguat and warfarin. to treat COPD exacerbations, and is the most potent fluoroquinolone Methods and Materials This single-centre, randomized, double-blind, inhibitor of CYP1A2. placebo-controlled, crossover, interaction study included healthy male Methods and Materials This phase I, open-label, non-randomised, volunteers aged 18--45 years. Riociguat (2.5 mg) or placebo was admin- fixed-sequence, two-period, single-centre study evaluated the effects of istered daily (t.i.d.) for 10 days. Warfarin sodium (25 mg) was adminis- steady-state enoxacin on the single-dose pharmacokinetics of roflumi- tered as a single oral dose 21 days before the study and on the 7th last and roflumilast N-oxide in 20 healthy volunteers. Subjects received day of treatment with riociguat or placebo. roflumilast 500 lg once daily on Days 1 and 12 and enoxacin 400 mg Results Twenty-one of the 30 subjects valid for safety analysis reported twice daily on Days 7--18. Pharmacokinetic profiles were obtained on a total of 89 treatment-emergent adverse events, all of which were of Days 2--6 and 7--20. The study also investigated the safety and tolera- mild (n = 64) or moderate (n = 25) severity. No serious adverse events bility of roflumilast administered alone and with enoxacin. occurred. The most frequently reported treatment-emergent adverse Results events considered to be related to riociguat and/or warfarin were dys- 19 subjects completed the study. For roflumilast, coadministration pepsia, headache, flatulence, nausea and vomiting. Data from 22 volun- resulted in a 56% higher mean systemic exposure and 20% higher teers were valid for pharmacodynamic and pharmacokinetic analyses. A mean peak concentration compared with roflumilast alone. For roflumi- single dose of warfarin did not affect the pharmacokinetics of riociguat last N-oxide, coadministration gave 23% higher mean systemic expo- to a clinically relevent extent. Riociguat at steady state did not affect sure and 14% lower mean peak concentration compared with Factor VII clotting activity or prothrombin time, and did not affect the roflumilast alone. Mean tPDE4i was 25% higher after coadministration pharmacokinetics of warfarin. compared with roflumilast alone. Roflumilast was equally well tolerated Conclusion Thus, riociguat and warfarin can be combined in patients when administered alone or with enoxacin, and no unexpected safety with PH, with no requirement for dose adaptation. issues were seen. Conclusion There was a weak interaction between roflumilast and e- noxacin, but this is unlikely to be clinically relevant as mean tPDE4i activity increased by only 25%.

24 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

47 SHORT-TERM EFFECT OF EFAVIRENZ ON IN VITRO METABOLISM OF MIDAZOLAM BY HUMAN LIVER MICROSOMES A. Keubler, J. Weiss, G. Mikus and J. Burhenne Department of Internal Medicine VI, Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany

Introduction The aim of this study was to investigate the effect of the non-nucleoside reverse transcriptase inhibitor efavirenz on the in vitro metabolism of midazolam. In vivo data suggest a possible acute activation of CYP3A metabolism by efavirenz. Methods and Materials The formation of 1¢-hydroxymidazolam was studied in pooled human liver microsomes (0.1 mg/ml) with and without addition of efavirenz (0.5--10.0 lM) over an incubation period of 20 minutes. Results The presence of efavirenz significantly increased the rate of 1¢- hydroxymidazolam formation by human liver microsomes in the samples containing midazolam concentrations up to 50 lM. Metabolite formation and Vmax values strongly correlated with increasing efavirenz concentrations at 0, 0.5, 1.0 and 5.0 lM. Conclusion The results clearly indicate a significant acute activation of midazolam metabolism by adding efavirenz to human liver microsomes. However, so far it is unclear, whether efavirenz itself or its main metabolite 8-hydroxyefavirenz is responsible for the activitation observed. Incubation of efavirenz with human liver microsomes leads to formation of significant amounts of its main metabolite 8-hydroxyefavirenz, although CYP2B6 is the major catalyst for this pathway. The activation observed has to be differentiated from induction, which is provoked by increased mRNA transcription. The increase in 1¢-hydroxymidazolam formation under efavirenz presence might have been caused by allosteric enzyme activation.

2009 The Authors 25 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

DRUG METABOLISM

48 49 PHARMACOGENOMICS OF CYP3A4: A ARE THERE DIFFERENCES BETWEEN HEALTHY PATHWAY ORIENTED CANDIDATE GENE VOLUNTEERS AND HIV-INFECTED PATIENTS IN APPROACH THE ACTIVITIES OF CYP3A, CYP2D6 AND K. Klein1, S. Winter1, M. Schwab1,2 and U. M. Zanger1 P-GLYCOPROTEIN? 1 Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, A. Jetter1,2,G.Fa¨tkenheuer3, D. Frank2, T. Klaassen2, A. Lazar2, 2 Auerbachstr. 112, 70376 Stuttgart, Department Clinical Pharmacology, A. Seeringer4, O. Doroshyenko2, J. Kirchheiner4, W. Hein5, University Hospital, Tuebingen, Germany E. Scho¨mig2, U. Fuhr2 and C. Wyen3 1Universita¨tsSpital Zu¨rich, Klinik fu¨r Klinische Pharmakologie und Introduction The cytochrome P450 (CYP) family member 3A4 is the Toxikologie, Ra¨mistrasse 100, 8091 Zu¨rich, Switzerland 2Klinikum der major drug metabolizing enzyme in adult human liver. CYP3A4 expres- Universita¨tzuKo¨ln, Institut fu¨r Pharmakologie, Klinische Pharmakologie, sion and function is highly variable inter- and intraindividually thus Gleueler Str. 24, 50931 Ko¨ln, 3Klinikum der Universita¨tzuKo¨ln, Klinik I fu¨r contributing to unpredictability in drug response and toxicity. The Innere Medizin, Kerpener Str. 62, 50924 Ko¨ln, 4Universita¨t Ulm, Institut fu¨r CYP3A4 promoter region spanning about 12 kb includes binding sites Naturheilkunde und Klinische Pharmakologie, Helmholtzstr. 20, 89081 for many transcription factors. We hypothesize that, in addition to SNPs Ulm, 5Klinikum der Universita¨tzuKo¨ln, Institut fu¨r Klinische Chemie, in the CYP3A locus, polymorphisms in factors directly or indirectly Kerpener Str. 62, 50924 Ko¨ln, Germany involved in the transcriptional regulation of CYP3A4 contribute to the observed variability. Introduction Studies suggested that infection and inflammation may Methods and Materials A set of 150 human liver samples with exten- lead to reduced activities of drug-metabolizing enzymes and drug sive patient documentation was phenotyped for CYP3A4 mRNA, pro- transporters. Here, we investigated whether these findings can be cor- tein and activity using TaqMan, Western blot and verapamil and roborated in HIV-infected patients using a cocktail phenotyping atorvastatin as probe drugs. Extensive literature and database search approach. identified polymorphisms in the CYP3A locus and in relevant candidate Methods and Materials A ‘phenotyping cocktail’ consisting of 1.5 mg genes. In addition haplotype ‘tagger SNPs’ were included Genotyping midazolam (intestinal and hepatic CYP3A), 30 mg dextromethorphan was performed on a Sequenom Maldi-TOF mass spectrometry platform. (CYP2D6), and 0.5 mg digoxin (P-glycoprotein) administered orally, and Results CYP3A4 expression was not normally distributed and varied of 1.0 mg midazolam intravenously four hours later (hepatic CYP3A >200fold at mRNA, protein and activity level. A selection of 13 known activity), was administered to 30 therapy-naı¨ve HIV-infected patients polymorphisms of the CYP3A locus (dbSNP and CYP allele databases; and to 12 healthy male controls. Plasma samples were analysed using http://www.cypalleles.ki.se/cyp3a4.htm) and >100 polymorphisms in immunoassays for digoxin and LC-MS/MS for all other analytes. Phar- about 20 genes including nuclear receptors (PXR, CAR, GR, VDR, SHP, macokinetics were calculated noncompartimentally. A parallel-group PPARa) and diverse transcription factors (HNF4a, HNF1, C/EBPa) were average bioequivalence approach was chosen for the comparison so far genotyped. Several of these polymorphisms were significantly between patients and volunteers. correlated with one or more of the CYP3A4-associated phenotypes Results In patients, mean apparent oral midazolam clearance (overall Conclusion The herein presented pathway-oriented approach to CYP3A activity) was 0.493-fold lower (90% confidence interval CI, CYP3A variability in human liver emphasizes the multifactorial nature 0.376--0.646) compared to the volunteers, while midazolam clearance of CYP3A4 phenotype variation. The goal is to develop a predictive sig- after intravenous dosing was not different (point estimate 1.101; 90% nature allowing diagnostics of CYP3A4 prior to drug therapy. CI, 0.911--1.331). In patients with at least one active CYP2D6 allele, the Acknowledgements Support: German Federal Ministry of Education molar metabolic ratio AUC /AUC was 1.671-fold and Research (HepatoSys grant 0313080I) and the Robert Bosch Foun- dextromethorphan dextrorphan higher than in volunteers (90% CI, 0.967--2.890) suggesting a lower dation, Stuttgart. CYP2D6 activity. In patients, digoxin AUC was 1.216 times the AUC observed in volunteers (90% CI, 0.969--1.526). Conclusion The activities of CYP3A, CYP2D6, and P-glycoprotein were lower in therapy-naı¨ve HIV-infected patients than in healthy volunteers, but, besides overall CYP3A activity, differences were small. Variabilities within the groups were higher than the discrepancies between them, which makes it unlikely that dose adaptations based on infection status would be useful.

26 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

50 51 PHENOTYPE--GENOTYPE ANALYSIS OF IDENTIFICATION AND CYP DEPENDENT CYP1A2 IN HEALTHY NON-SMOKING METABOLISM OF ENDOGENOUS FATTY ACID VOLUNTEERS DERIVATIVES IN HUMAN PLASMA A. Balogh1 and U. Merkel2 C. Queckenberg, G. Zadoyan, D. Rokitta, C. Breuer and U. Fuhr 1Institut fu¨r Pharmakologie und Toxikologie, Drackendorfer Str. 1, 07747 Institut fu¨r Pharmakologie, Klinische Pharmakologie, Gleueler Str. 24, Jena, 2Institut fu¨r Pharmakologie und Toxikologie, Dornburgerstr. 159, 50931 Ko¨ln, Germany 07747 Jena, Germany Introduction Fatty acids such as arachidonic acid and oleic acid are Introduction This study was designed to better understand genetic substrates of cytochrome P450 enzymes, thus generating bioactive variation of the cytochrome P450 (CYP) gene CYP1A2*1F and its metabolites. Derivatives of fatty acids (e.g. endocannabinoids: ananda- impact on CYP1A2 activity in healthy subjects. Therefore, CYP1A2 mide, 2-arachidonoylglycerole [2-AG]) and fatty acid amides (oleoyle- enzyme activity was determined on the basis of the pharmacokinetics thanolamide, palmitoylethanolamide) are important neurotransmitters, of caffeine and two metabolites, used as an index of in vivo activity but human metabolism by cytochrome P450 enzymes is not yet eluci- (phenotype), and the most important single nucleotide polymorphism dated. --163C > A (CYP 1A2*1F) was assessed (genotype). Methods and Materials Our objective was to detect new endogenous Methods and Materials In 99 male healthy non-smokers (aged fatty acid derivatives in human plasma and to investigate their metab- between 20 and 60 years) the plasma concentrations of caffeine olism, as well as the metabolism of anandamide, 2-AG, oleoylethanola- (137X), paraxanthine (17X) and theophylline (13X) were determined 4 mide and palmitoylethanolamide. All substances were incubated with and 8 hours after oral administration of 200 mg caffeine with HPLC the recombinant enzymes CYP2C8, CYP3A4 and CYP2C9*1, CYP2C9*2 analysis, and the elimination half-life time of caffeine was calculated. and CYP2C9*3. Analysis was done by LC-MS/MS. Genotyping of CYP1A2*1F (A/A, A/C and C/C) was performed by PCR. Results N-oleoylglycine was discovered in the plasma of nine healthy Results Following genotype frequencies of CYP 1A2*1F were identified: subjects being screened for this purpose (range: 3.2--19.5; mean: 0.495 A/A, 0.414 A/C and 0.091 C/C. This distribution is in accordance 8.8 pmol/ml). 2-AG was metabolized by all enzymes tested. Ananda- with the frequencies expected, when applying the Hardy-Weinberg mide was metabolized by all allelic variants of CYP2C9. As metabolites principle based on the experimentally determined frequency of the C/ of anandamide, 8,9-epoxyeicosatrienoic acid ethanolamide (8,9-EET-EA), C genotype (v2 = 0.0101). In subjects carrying the C/C genotype the 11,12-EET-EA, 14,15-EET-EA and 20-hydroxyeicosatetraenoic acid ethan- half-life time of caffeine was 20% and/or 40% longer (7.83 ± 5.74 h) olamide (20-HETE-EA) could be detected. N-oleoylglycine was metabo- than in those carrying the A/C (6.42 ± 4.25 h) and A/A genotypes lized by CYP2C9*1, CYP2C9*2 and CYP2C8; here, 9,10-epoxy-N- (5.56 ± 2.71 h), respectively. These differences between genotypes oleoylglycine was detected as a metabolite of CYP2C9*1 and were not statistically significant. In addition the plasma caffeine metab- CYP2C9*2. The epoxidation by CYP2C9*1 was saturable (Km: 14.6 lM; olite ratio (17X/137X) was markedly lower in C/C individuals 4 h after Vmax: 0.22 nmol/min/mg enzyme). Oleoylethanolamide was a substrate oral intake of caffeine (0.383 ± 0.197 C/C, 0.421 ± 0.131 A/C, of CYP3A4 and CYP2C8. Palmitoylethanolamide was metabolized by 0.472 ± 0.176 A/A) and 8 h after intake (0.737 ± 0.432 C/C, CYP2C8; this metabolism was saturable with a Km of 3.1 lM and Vmax 0.776 ± 0.283 A/C, 0.884 ± 0.354 A/A) but not significantly. The plasma of 83 pmol/min/mg). Enzyme kinetics of all other degradations was not concentrations of paraxanthine were not so noticeable differently saturable. among the genotypes. Conclusion Our results suggest that several endogenous fatty acid Conclusion Although there was a trend to decreased CYP1A2 activity derivatives are physiological substrates of cytochrome P450 enzymes. in C/C carriers no statistically significant effect of CYP1A2*1F mutation Further studies will address the biological relevance of these deriva- on CYP1A2 activity in healthy non-smoking men was observed. tives, including their metabolites.

2009 The Authors 27 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

52 53 CONVERSION OF AZATHIOPRINE TO SYSTEMATIC ANALYSIS OF NUCLEOSIDE MERCAPTOPURINE IS NOT A FUNCTION OF DIPHOSPHATE KINASE ISOFORM A AND B IN GENDER HUMAN TISSUES K. Dilger1, D. Lehnick2 and J. Heuer2 S. Karner1, E. Schaeffeler1, S. Shi1,2, O. Burk1, K. Klein1, 1Dr. Falk Pharma GmbH, Leinenweberstrasse 5, 79041 Freiburg, 2AAI U. M. Zanger1, U. Hofmann1 and M. Schwab1,3 Pharma Deutschland GmbH und Co.KG, Neu-Ulm, Germany 1Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology and University of Tuebingen, Stuttgart, Germany 2Huazhong University of Introduction Azathioprine is cleaved in a non-enzymatic reaction with Science and Technology, Department of Pharmacy of Union Hospital, glutathione to mercaptopurine, which is subsequently metabolized to Tongji Medical College, Wuhan, China 3Deparment of Clinical the presumed active metabolites with immune-modifier activity. In clin- Pharmacology, University Hospital Tuebingen, Tu¨bingen, Germany ical practice azathioprine (2--2.5 mg/kg) and mercaptopurine (1-- 1.5 mg/kg) are used interchangeably for the treatment of inflammatory Introduction One important way in which the immunosuppressant bowel diseases. The aim was to investigate if there is a gender differ- azathioprine exerts its activity is caused by the metabolite 6-thioguano- ence in the conversion of the prodrug azathioprine to mercaptopurine. sine triphosphate (TGTP). The conversion of 6--thioguanosine diphos- Methods and Materials Thirty-three healthy, non-smoking females phate (TGDP) into active 6-thioguanosine triphosphate (TGTP) is (range, 24--48 years, 51--85 kg) and 33 healthy, non-smoking males mediated by nucleoside diphosphate kinase (NDPK). The two most (range, 23--50 years, 60--92 kg) with normal thiopurine methyltransfer- widely studied human NDPK isoforms, NDPK A and B, which are 88% ase activity received a single dose of 100 mg of azathioprine (two identical at the protein level, provide over 95% of NDPK activity. Their 50 mg tablets). Twenty-one blood samples were collected during official gene symbols are NME1 (NDPKA) and NME2 (NDPKB). 24 hours after drug intake for simultaneous determination of azathio- Methods and Materials We analysed NME1 and NME2 mRNA expres- prine and mercaptopurine. Lower limit of quantification of validated sion in a set of 20 different tumors and normal human tissues. Next, liquid chromatography tandem mass spectrometry was 1 ng/ml in we systematically examined both isoforms on the level of mRNA, pro- plasma for both analytes. Pharmacokinetic analysis using standard non- tein and activity in 100 human livers. Performing DNA sequencing and compartmental model comprised calculation of metabolic ratios (mer- MALDI-TOF MS analysis, we additionally screened for NDPK genetic captopurine/azathioprine) for all major pharmacokinetic parameters variants. such as area under the plasma concentration time curve, AUCt [ng*h/ Results NME1 and NME2 were expressed in every analysed tissue but ml], maximum plasma concentration, Cmax [ng/ml], and apparent oral at different levels. Expression in various tumor tissues was significantly clearance, Cl/f [ml/min/kg]. Data are given as arithmetic mean ± SD in higher than compared to normal tissues (testis P < 0.005; thyroid gland order to allow comparison with historical data. P = 0.008). For human liver, we found a 65-fold (NME1) and a 15-fold Results Gender did not affect pharmacokinetics of azathioprine. E.g., (NME2) variability of mRNA expression. On protein level, there was a AUCt was 33.0 ± 24.7 ng*h/ml in females and 38.0 ± 45.1 ng*h/ml in 12-fold (NDPK A) and 28-fold (NDPK B) variability. For NDPK activity, a males, and Cmax was 27.0 ± 29.8 ng/ml in females and 35.7 ± 47.3 ng/ five-fold variability was detected. Furthermore, we identified known ml in males. Interestingly, metabolic ratios were found to be almost and novel genetic variants altering in part NDPK expression. identical in female and male subjects: 2.25 ± 1.34 versus 2.33 ± 1.78 Conclusion NDPK expression is highly variable in different tissues for AUCt; 1.51 ± 0.91 versus 1.46 ± 1.18 for Cmax; 0.71 ± 0.59 versus including tumors. Since NDPK A and B genetic variants alter NDPK 0.63 ± 0.57 for Cl/f (females versus males). Accordingly, none of the expression, we suggest that genetic factors contribute to interindividu- above given statistical comparisons between females and males al variability in conversion of TGDP to TGTP. showed a significant difference (Mann--Whitney test). Acknowledgements Supported by the Robert-Bosch Foundation, Conclusion Gender is not an important factor to be considered in con- Stuttgart, Germany. version of azathioprine to mercaptopurine.

28 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

54 PHARMACOKINETICS AND METABOLISM OF FLUPIRTINE IN MAN GENOTYPED FOR NAT2, UGT1A1 AND GSTP1 E. Scheuch1, C. Modeß1, A. Nasif1, M. Gru¨ndling2, K. Methling1, B. Terhaag3 and W. Siegmund1 1Universita¨t Greifswald/Inst. Pharmakologie, Klinische Pharmakologie, Loefflerstrasse 23d, 17487 Greifswald, 2Universita¨t Greifswald/Klinik fu¨r Ana¨sthesiologie, Loefflerstrasse 23, 17487 Greifswald, 3AWD Pharma GmbH & Co. KG, Wasastrasse 50, 01445 Radebeul, Germany

Introduction In observational studies it was shown that the analgesic flupirtine (FLU) may cause hepatic side effects. There may be a pharma- cogenetic background for FLU hepatotoxicity, because FLU undergoes complete biotransformation by polymorphic enzymes such as the NAT2, glucuronosyltransferases (UGT) and glutathione S-transferase (GST). Methods and Materials A pharmacokinetic study was performed in 36 healthy subjects of which nine were rapid acetylators, nine slow acetylators (SA) of NAT2, six SA and carriers of two UGT1A1*7 alleles, six SA and carriers of at least two deficient GSTP1 alleles and six SA with variant UGT1A1 and GSTP1 alleles. Plasma concentration time curves and urinary and faecal excretion of FLU, D13223 (major metabolite), glucu- ronides and mercapturic acid derivatives were measured after single intravenous and oral administration (100 mg) and repeated oral administration (400 mg s.i.d.) for 5 days using LC-MS/MS. Results Disposition of FLU (single dose and steady state) was not significantly influenced by genetic polymorphisms of NAT2, UGT1A1 and GSTP1 despite some statistical trends of the pharmacokinetic data. The treatment with FLU was safe and well tolerated. FLU exerted a significant analgesic effect as shown by increased electric pain threshold and delayed onset of muscle soreness (DOMS). Conclusion Genetic polymorphisms of NAT2, UGT1A1 and GSTP1 are obviously no major variables in disposition of FLU.

2009 The Authors 29 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

DRUG TRANSPORTERS

55 56 INFLUENCE OF CYCLOOXYGENASE THE INFLUENCE OF FREQUENT GENETIC INHIBITORS ON THE FUNCTION OF THE VARIATIONS ON THE TRANSPORT ACTIVITY PROSTAGLANDIN TRANSPORTER OATP2A1 OF OATP1B1 EXPRESSED IN HUMAN GASTRIC MUCOSA C. Fahrmayr, M. F. Fromm and J. Ko¨nig K. Mandery1, K. Bujok1, I. Schmidt1, T. T. Rau2, M. F. Fromm1 Friedrich-Alexander-Universita¨t Erlangen-Nu¨rnberg, Institut fu¨r and H. Glaeser1 Experimentelle und Klinische Pharmakologie und Toxikologie, Fahrstraße 1Friedrich-Alexander-Universita¨t Erlangen-Nu¨rnberg, Institut fu¨r 17, 91054 Erlangen, Germany Experimentelle und Klinische Pharmakologie und Toxikologie, Fahrstraße 17, 91054 Erlangen, 2Friedrich-Alexander-Universita¨t Erlangen-Nu¨rnberg, Introduction OATP1B1 (gene symbol SLCO1B1) is the best character- Pathologisches Institut, Krankenhausstraße 12, 91054 Erlangen, Germany ized member of the human OATP (organic anion transporting polypep- tides) family. It localizes in the basolateral membrane of human Introduction The prostaglandin transporter OATP2A1, a member of hepatocytes mediating the uptake of several endogenous compounds the human organic anion transporting polypeptide family, plays an and xenobiotics. Substrates for OATP1B1 include hormones and bile important role for local distribution of prostaglandins. These mediators salts as well as several widely prescribed drugs such as statins (pravast- are a pivotal factor for the integrity of gastric mucosa. Treatment with atin), antibiotics and anticancer agents. There is clear in vitro and in cyclooxygenase (COX) inhibitors can lead to serious side effects such vivo evidence that OATP1B1 is an integral part of the hepatic elimina- as ulceration and bleeding. However, little is known about the localization of drugs. Alterations in transport activity affect pharmacokinetics tion of OATP2A1 and the impact of COX inhibitors on the function of of a given drug substrate and it has been shown that genetic varia- the prostaglandin transporter OATP2A1 in the upper gastrointestinal tions (polymorphisms) in the SLCO1B1 gene alter OATP1B1-mediated tract. transport. In vivo this has been demonstrated for the frequent variation Methods and Materials We investigated the localization of OATP2A1 SLCO1B1c.521T>C which alters the pharmacokinetics of multiple drugs, in human gastric mucosa using immunohistochemistry and investi- e.g. pravastatin. gated the influence of different COX inhibitors on the OATP2A1 trans- Methods and Materials To further elucidate the functional conse- port activity using HEK293 cells overexpressing OATP2A1. quences of frequent polymorphisms in the SLCO1B1 gene we estab- Results OATP2A1 was localized in the neck region and deep pyloric lished HEK-cells stably expressing the OATP1B1 variants *1b (c.388A>G), *5 (c.521T>C) and *15 (c.388A>G + c.521T>C). Using glands of antrum and in parietal cells of human gastric corpus. Diclofe- 3 nac and lumiracoxib were potent inhibitors of OATP2A1-mediated [ H]BSP (bromosulfophthalein) as model substrate we investigated uptake kinetics of the different OATP1B1 proteins. PGE2 transport in vitro with IC50 values of 4.6 ± 1.1 lM and 5.8 ± 1.2 lM. In contrast, indomethacin, ketoprofen, and naproxen led Results Interestingly, all variants lead to a reduced Km-value (*1b: 0.08 lM; *5: 0.09 lM; *15: 0.13 lM) compared to OATP1B1-WT cells to significant stimulation of OATP2A1-mediated PGE2 transport by 124.3 ± 8.7%, 78.0 ± 0.8%, and 46.1 ± 4.2%, respectively. A further (Km: 0.26 lM) and decreased Vmax-values (*1b: 67 pmol/mg protein/ detailed investigation of the stimulation of OATP2A1 function by indo- 10 min; *5: 66 pmol/mg protein/10 min; *15: 107 pmol/mg protein/ methacin and ketoprofen revealed that increasing concentrations of 10 min) compared to the OATP1B1-WT Vmax-value (218 pmol/mg protein/10 min). these cyclooxygenase inhibitors lead to changes in Vmax, indicating that these drugs can change the transport activity of OATP2A1. Conclusion These results demonstrate that HEK-cells expressing differ- Conclusion The prostaglandin transporter OATP2A1 expressed in ent OATP1B1 variants are suitable models for the systematic analysis of human stomach may play an important role for the prostaglandin- the impact of these genetic variations on OATP1B1-mediated drug dependent protection of gastric mucosa. The distinct effects of various transport. clinically used COX inhibitors on OATP2A1 function might contribute to differences in gastrointestinal side effects of these drugs.

30 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

57 58 EXPRESSION AND LOCALIZATION OF INTERINDIVIDUAL VARIABILITY OF OATP3A1 AND OATP5A1 IN MALIGNANT AND MULTIDRUG RESISTANCE PROTEIN 2 (ABCC2) NON-MALIGNANT BREAST TISSUE EXPRESSION IN HUMAN LIVER: IMPACT OF J. Kindla1, R. Jung2, P. A. Fasching3, R. Strick3, R. Sto¨hr2, ABCC2 POLYMORPHISMS 2 1 1 A. Hartmann , M. F. Fromm and J. Ko¨nig T. Lang1, M. R. Toliat2, T. Yan1,U.Go¨dtel-Armbrust1, K. Klein3, 1 Friedrich-Alexander-Universita¨t Erlangen Nu¨rnberg, Institut fu¨r U. M. Zanger3, L. Wojnowski1, M. F. Fromm4 and H. Glaeser4 Experimentelle und Klinische Pharmakologie und Toxikologie, Fahrstraße 1Universita¨tsmedizin der Johannes Gutenberg-Universita¨t Mainz, Institut 2 17, 91054 Erlangen, Friedrich-Alexander-Universita¨t Erlangen-Nu¨rnberg, fu¨r Pharmakologie, Obere Zahlbacherstr. 67, 55101 Mainz, 2Universita¨tzu 3 Pathologisches Insitut, Krankenhausstraße 12, 91054 Erlangen, Friedrich- Ko¨ln, Cologne Center for Genomics (CCG), Zu¨lpicher Straße 47, 50674 Alexander-Universita¨t Erlangen-Nu¨rnberg, Frauenklinik, Universita¨tsstraße Ko¨ln, 3Dr. Margarete Fischer-Bosch-Institut fu¨r Klinische Pharmakologie, 21-23, 91054 Erlangen, Germany Auerbachstraße 112, 70376 Stuttgart, 4Friedrich-Alexander-Universita¨t Erlangen-Nu¨rnberg, Institut fu¨r Experimentelle und Klinische Introduction Members of the organic anion transporting polypeptide Pharmakologie und Toxikologie, Fahrstraße 17, 91054 Erlangen, Germany (OATP) family are expressed in various organs, including tumorous tissues and mediate the uptake of endogenous compounds such as Introduction The reasons underlying the pronounced inter-individual estrone-3-sulfate or prostaglandin E2 as well as drugs such as HMG- variability in the hepatic MRP2 expression in humans are incompletely CoA-reductase inhibitors (e.g. pravastatin) and cytotoxic agents (e.g. understood, but may include genetic polymorphisms of the encoding paclitaxel) into cells. For the therapy of breast cancer, the OATP-medi- gene ABCC2. ated uptake of anticancer agents may be pivotal, but today little is Methods and Materials We investigated the variability in MRP2 known about the expression and function of OATP family members in expression in normal liver samples from a white population in relation breast cancer tissue. to 12 single nucleotide polymorphisms (SNPs). Hepatic MRP2 mRNA Methods and Materials We investigated the expression and localiza- (n = 137) and protein (n = 178) expression was determined by real tion of OATPs in human malignant and non-malignant breast tissues time quantitative PCR and Western Blot analysis from nuclear/mem- using quantitative real-time PCR, immunofluorescence and immunohis- brane pellets. Each individual was genotyped for the following poly- tochemistry analyses. morphisms in ABCC2: -1774delG, -1549G>A, -1023G>A, -1019A>G, - Results Quantitative real-time PCR revealed that SLCO3A1 (encoding 24C>T, IVS3-49C>T, 1249G>A, 2761G>A, 3107T>C, 3563T>A, 3972C>T, OATP3A1) and SLCO5A1 mRNA (encoding OATP5A1) is highly 4544G>A. We have carried out further in vitro investigations based on expressed [mean SLCO3A1 mRNA expression 3.6% of ß-actin, 95% CI: the obtained results. 2.3--5.0%; mean SLCO5A1 mRNA expression 13.3% of ß-actin, 95% CI: Results MRP2 mRNA and protein expression varied 81- and 155-fold. 7.4--19.2%)]. Immunofluorescence analyses demonstrated that OATP3A1 Five polymorphisms (-1549G>A; allele frequency: 37.2%, -1019A>G; and OATP5A1 are both localized in epithelial cells of the thoracic duct 37.2%, IVS3-49T; 37.2%, 3563T>A; 5.1%, 4544G>A, 4.8%) were signifi- and in capillary endothelium in non-tumorous tissue and both were cantly associated with higher protein expression. These results were also detected in breast cancer samples. Furthermore, immunohisto- substantiated by haplotype analysis. Fiveteen ABCC2 haplotypes were chemistry analyses of malignant and non-malignant breast tissues were identified in the studied DNA samples. The presence of the ABCC2*4 performed. Both proteins were localized intracellularly and in the (-1549A; -1019G; IVS3-49T; 3972T, haplotype frequency: 12%) plasma membrane of tumorous cells. ABCC2*6 (-1549A; -1019G; IVS3-49T; 3563A; 4544A, 5%), and ABCC2*7 Conclusion Our analyses demonstrated that OATP3A1 and OATP5A1 (-1549A; -1019G; IVS3-49T, 3%) haplotypes was associated with a sig- are expressed in malignant and non-malignant breast tissue. Further nificantly higher hepatic protein expression of MRP2. The linked vari- analyses regarding the substrate spectrum of both transporters are ants 3563T>A (V1188E) and 4544G>A (C1515Y) showed a 2-fold necessary in order to clarify the role of both OATP family members for higher protein expression compared to wild-type MRP2 in HEK293 the sensitivity or insensitivity of breast cancer tissue to chemothera- cells using immunoblotting experiments. Hepatic MRP2 mRNA peutic agents during cancer treatment. expression and measured luciferase reporter gene activity were not dependent on the MRP2 promoter polymorphisms -1549G>A and -1019A>G. Conclusion Our study shows the existence of ABCC2 gene variants which are associated with altered hepatic levels of MRP2. With a higher protein expression, the double variant 3563T>A and 4544G>A contributes to some extent to the observed variability.

2009 The Authors 31 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

59 60 POTENTIAL OF NOVEL ANTIRETROVIRALS TO EFFECT OF CAVEOLIN-1 KNOCKDOWN ON MODULATE EXPRESSION AND FUNCTION OF THE ACTIVITY OF BREAST CANCER ABC-TRANSPORTERS RESISTANCE PROTEIN N. Zembruski, G. Bu¨chel, L. Jo¨dicke, W. E. Haefeli and J. Weiss M. Herzog1, C. H. Storch1, P. Gut1,J.Fu¨llekrug2, R. Ehehalt2, Department of Internal Medicine VI, Clinical Pharmacology and W. E. Haefeli1 and J. Weiss1 Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 1Department of Internal Medicine VI, Clinical Pharmacology and 410, 69120 Heidelberg, Germany Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, 2Department of Internal Medicine IV, Introduction The chemokine receptor antagonists maraviroc and vicri- Gastroenterology, Hepatology, Infectious Diseases, and Intoxications, viroc and the integrase inhibitors elvitegravir and raltegravir are novel University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, antiretroviral agents used for the treatment of HIV infections. ATP-bind- Germany ing cassette (ABC-) transporters as modulators of effectiveness and safety of antiretroviral therapy can mediate virus resistance and clini- Introduction The breast cancer resistance protein (BCRP/ABCG2) plays cally significant drug-drug interactions. Several interactions involving a decisive role in drug resistance of cancer cells. Previous data demon- these new compounds have been observed in patients that are not strate a co-localisation of BCRP with caveolin-1 (cav-1), an integral completely understood due to limited data available on these antiret- membrane protein of lipid rafts and a structural component of cavoe- rovirals. To expand the knowledge on ABC-transporter mediated drug- lae. Moreover, cav-1 is linked to an aggressive phenotype of cancer drug interactions of these new HIV drugs we investigated whether cells in different kinds of tumours. We therefore investigated, whether these compounds are substrates, inhibitors, or inducers of ABC-trans- cav-1 is of functional importance for BCRP activity. porters. Methods and Materials Cav-1 was knocked down in MDCKII-BCRP Methods and Materials We evaluated P-glycoprotein (P-gp) inhibitory cells and the corresponding parental cell line MDCKII by transduction potential by calcein assay in P388/dx and L-MDR1 cells. The inhibitory with a retroviral RNAi vector (pRVH1-puro-cav1). After selection, the potential on breast cancer resistance protein (BCRP) was assessed by knockdown efficiency was examined by quantitative real-time reverse flow cytometric pheophorbide A efflux in MDCKII-BCRP cells. Substrate transcriptase polymerase chain reaction (RT-PCR) and by western blot. characteristics were evaluated by growth inhibition assays in MDCKII Effects on BCRP function were investigated by flow cytometry (pheo- cells overexpressing human MDR1, BCRP, MRP1, MRP2, or MRP3. Induc- phorbide A efflux assay) and proliferation assays to quantify changes in tion was quantified by real-time RT-PCR in LS180 cells after four days the resistance of the cells towards cytostatic BCRP substrates. of treatment. Results Cav-1 knockdown by about 80% diminished BCRP activity by Results Elvitegravir and vicriviroc inhibited P-gp in P388/dx and L- 35% in MDCKII-BCRP cells but not in mock-treated control cells. More- MDR1 cells (f2 values for P388/dx: 3.4 ± 1.2 lM (elvitegravir), over, the resistance to the BCRP substrate mitoxantrone was signifi- 8.4 ± 3.6 lM (vicriviroc)). The IC50 for BCRP inhibition was cantly reduced in MDCKII-BCRP cav-1 knockdown cells compared to 15.7 ± 5.7 lM for elvitegravir and 237 ± 93 lM for vicriviroc. Raltegra- untreated and mock-treated cells. Results obtained with western blot vir and maraviroc showed no evidence of P-gp or BCRP inhibition. analysis of the gradient ultracentrifugation fractions of the knockdown Growth inhibition assays suggest that all compounds investigated are cells indicated that cav-1 knockdown does not displace BCRP in the substrates of P-gp. Induction assays demonstrate that mRNA expres- plasma membrane. It therefore seems plausible that the diminished sion of several ABC-transporters is induced by these antiretrovirals in BCRP function after cav-1 knockdown can be attributed to a disruption LS180 cells. of the protein-protein interaction between cav-1 and BCRP. Conclusion In conclusion, the new anti-HIV drugs have the potential Conclusion In conclusion our results argue for a positive regulation of to modulate expression and function of several ABC-transporters. BCRP function by cav-1. Acknowledgements This project was supported by the Wilhelm San- der-Stiftung (Grant # 2008.005-1).

32 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

ANALYTICAL METHODS

61 62 MULTIPLE ELECTRODE PLATELET ASSAY TO STUDY DRUG--DRUG AGGREGOMETRY COMPARED WITH LIGHT INTERACTIONS BETWEEN CITALOPRAME AND TRANSMISSION AGGREGOMETRY AND ADDITIONALLY PRESCRIBED PSYCHOTROPIC VERIFYNOW P2Y12 ASSAY FOR ASSESSMENT DRUGS IN HUMAN LIVER MICROSOMES OF PLATELET REACTIVITY IN PATIENTS R. Brandl, T. Jahner, S. Beck, D. Melchner and E. Haen TREATED WITH CLOPIDOGREL AFTER PCI Klinikum der Universita¨t Regensburg, Klinische Pharmakologie, Franz-Josef-Strauss-Allee, 93053 Regensburg, Germany D. Trenk, W. Hochholzer, M. Cap, S. Leggewie, M. Zhao, C. Stratz, C. M. Valina and F.-J. Neumann Introduction Citaloprame is one of the most frequently prescribed Herz-Zentrum Bad Krozingen, Su¨dring 15, 79189 Bad Krozingen, Germany selective serotonin reuptake-inhibitor (SSRI) in the AGATE hospitals (Ar- beitsgemeinschaft Arzneimitteltherapie bei psychiatrischen Erkrankun- Introduction Enhanced platelet reactivity despite treatment with clopi- gen). It is metabolized in the liver by the cytochrome-P450-isoenzymes dogrel is associated with an increased risk for adverse cardiovascular (CYP) 2C19, 2D6 and 3A4. Drug-drug-interactions are rarely observed in events following percutaneous coronary intervention with stenting clinical routine under citaloprame. However, when quantifying drug (PCI). Patients with a residual platelet aggregation >14% determined at concentrations in psychiatric patients we do see increased concentra- day 1 after PCI by light transmission aggregometry (LTA) using 5 lM tions of various drugs that are metabolized via the same CYP isoen- adenosine diphosphate (ADP) incurred a more than 3-fold risk for zymes. We currently develop an in vitro method to study in human death and myocardial infarction during 12-months follow-up in EXCEL- liver microsomes the effect of one or more drugs actually found in the SIOR (Trenk et al., 2008). LTA in platelet rich plasma (PRP) is considered comedication of patients on citaloprame. to be the gold standard despite several methodological disadvantages. Aim This method is set up to study the influence of drugs indicated as The VerifyNow P2Y12 assay (VN) in whole blood was recently estab- comedication to citaloprame in our TDM specimens. lished as an attractive alternative to LTA. Multiple electrode platelet Methods and Materials Human liver microsomes are incubated in a aggregometry (MEA) is a new method for rapid measurement of ADP- concentration of 1.3 mg/ml with dipotassiumhydrogenphosphatebuffer induced platelet aggregation in whole blood. We, therefore, compared (0,1M, pH7,4), NADPH regenerating system and citaloprame at a tem- on-treatment platelet reactivity by VN and MEA with LTA in patients perature of 37C. Starting at 0 min (baseline) the incubation is stopped treated with clopidogrel after PCI with stent implantation. at several time points over two days in aliquots by addition of ice-cold Methods and Materials Blood samples were obtained from 307 acetonitrile. After removing the human liver microsomes by centrifuga- patients on dual antiplatelet therapy (clopidogrel + aspirin) at day 1 tion citaloprame concentration is measured by HPLC using a method after PCI. Platelet reactivity was determined in PRP by LTA (ADP 5 lM), developed for therapeutic drug monitoring [Greiner et al.]. A crucial in whole blood by VN P2Y12 and in blood diluted 1:2 with saline by parameter for these type of experiments is the elimination half life of MEA after stimulation with ADP (MEA ADP) or with ADP plus prosta- the drugs under study. Therefore, to monitor citalopram metabolism glandin E1 (MEA ADP_PGE). Platelet reactivity was assessed as residual (t = 19--45) the enzyme reaction has to be monitored over at least platelet aggregation (RPA) by LTA, P2Y12 Reaction Units (PRU) by VN 1/2 two days. and as area under the curve (AUC) using MEA. Results The citaloprame concentration decreases from 201 ng/ml at Results Receiver-operator characteristic (ROC) analysis was used to dis- 0 hours to 110 ng/ml at 25 hours, which is in good agreement with tinguish between patients below and above the LTA cut point of 14%. the known elimination half life. For about 16 hours the concentration ROC areas under the curve and the sensitivities associated with a speci- remained at basal level which had been measured at the beginning of ficity of 90% are summarized in the table below. the experiment. After this time period the citaloprame concentration starts to decrease Table 1. Results of ROC Analysis Conclusion With this assay we can monitor the elimination of citalopram. In future experiments we want to study this process in the pres- ROC Cut Sensitivity for AUC P-value point cut point ence of comedicated drugs. Reference VN versus LTA 0.833 <0.001 208 PRU 0.52 1. Greiner C., Hiemke C., Bader W., Haen E.; Determination of citalop- MEA ADP versus LTA 0.778 <0.001 355 AU 0.36 ram and escitalopram together with their active main metabolites MEA ADP_PGE versus LTA 0.734 <0.001 207 AU 0.40 desmethyl(es-)citalopram in human serum by column-switching high performance liquid chromatography (HPLC) and spectrophotometric detection. J Chromatogr B Analyt Technol Biomed Life Sci, 2007. Conclusion A PRU value of 208 by VN identified patients with LTA- 848(2): 391--394. defined inadequate antiplatelet response (RPA > 14%) with reasonable sensitivity. ROC analysis with MEA (ADP/ADP + PGE) provided lower sensitivities.

2009 The Authors 33 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

63 64 AN LC/MS/MS ASSAY FOR THE DEVELOPMENT OF A SELECTIVE AND INTRACELLULAR QUANTIFICATION OF SENSITIVE HPLC/FLUORESCENCE ASSAY FOR CISPLATIN IN VITRO QUANTIFICATION OF DOXORUBICIN IN RAT S. Stoeva1, D. Theile1, C. Herold-Mende2, J. Weiss1, PLASMA RELEASED FROM NANOPARTICLES 1 1 W. E. Haefeli and J. Burhenne R. M. M. Ali1, I. Reimold2, G. Fricker2, W. E. Haefeli1 and 1 Department of Internal Medicine VI, Clinical Pharmacology and J. Burhenne1 Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 1Department of Internal Medicine VI, Clinical Pharmacology and 2 410, 69120 Heidelberg, Department of Neurosurgery, University of Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany 410, 69120 Heidelberg, 2University of Heidelberg, Institute of Pharmacy and Molecular Biotechnology, Im Neuenheimer Feld 364, 69120 Introduction An LC/MS/MS method for intracellular quantification of Heidelberg, Germany the chemotherapeutic cisplatin was developed, validated, and applied to three human tumour cell lines derived from head and neck squa- Introduction Doxorubicin is used to treat cerebral malignancies but if mous cell carcinomas to compare chemotherapeutic resistance and the drug reaches myocardial tissue it frequently causes severe cardiac sensitivity with intracellular concentrations. adverse effects. Therefore the ability of doxorubicin bound to poly-n- Methods and Materials Human tumour cell lines HNO97, HNO206, and butylcyano-acrylate nanoparticles to cross the blood-brain barrier and HNO237 were incubated with 5, 10, and 20 lM cisplatin at 37C for 1 and release doxorubicin at the site of action is of interest. The aim of this 4 h. Derivatisation with diethyldithiocarbamate (DDTC) was used for study was to develop an HPLC assay for the quantification of free quantification which converted cisplatin and palladium(II)acetate (internal doxorubicin in plasma and to subsequently expand the assay to tissue. standard) to Pt(DDTC)2 and Pd(DDTC)2, respectively. After liquid/liquid Methods and Materials Protein precipitation was used for sample extraction (tert-butylmethylether), complexes were chromatographed on preparation. Quantification was performed by HPLC/fluorescence. The a Luna RP18 column with 5 mM ammonium acetate and acetonitrile assay was validated according to the recommendation of the FDA and (mobile phase) and detected by positive selected reaction monitoring and applied to quantify free plasma doxorubicin released from nanoparti- tandem mass spectrometry using the following mass transitions: m/z cles in vivo after single oral application (250 mg/kg nanoparticles con- 492 ﬁ m/z 116 (Pt(DDTC)2) and m/z 403 ﬁ m/z 116 (Pd(DDTC)2). taining 20.6 mg doxorubicin) and intravenous administration of 80 mg/ Results Calibration for Pt(DDTC)2 was established in the range of 0.01-- kg doxorubicin nanoparticles (containing 6.6 mg doxorubicin) to rats. 20.0 lM. The recovery of Pt(DDTC)2 ranged between 63.3%--77.7%. Results Doxorubicin and the internal standard daunorubicin were suc- Within-batch precision (batch-to-batch) was in the range of 2.9--8.8% cessfully separated on a Synergy Fusion RP column using gradient elution (4.7--5.7%). Within-batch accuracy (batch-to-batch) ranged from 96.9-- with ammonium acetate and acetonitrile. In rat plasma doxorubicin was 108.0% (93.1%--102.3%). The assay fulfilled all recommendations of the quantified from 6.25 to 1600 ng/ml with accuracy of 97--104%, and preci- FDA guideline concerning accuracy, precision, selectivity, and stability. sion of 1.1--8.3% CV (within-batch) and 4.2--5.6% CV (batch-to-batch). Quantification of cisplatin in HNO cells resulted in concentrations Doxorubicin was not found in rat plasma after oral application. Intravenous between 0.01 and 0.10 lM matching the resistance of the cell lines application led to doxorubicin plasma concentrations up to 13.2 ng/ml. towards cisplatin. Conclusion Protein precipitation and liquid/liquid extraction in combi- Conclusion The analytical method is a rapid and reliable technique for nation with HPLC/fluorescence allowed quantifying free doxorubicin the in vitro quantification of cisplatin. This was demonstrated by quan- released from poly-n-butylcyano-acrylate nanoparticles in rat plasma. tification of intracellular concentrations of cisplatin in three human The low plasma concentrations imply low release of doxorubicin in tumour cell lines. The measured intracellular cisplatin concentrations plasma. Doxorubicin quantification in tissue samples will now follow to provided evidence for the uptake of cisplatin in correlation with the quantify its distribution to brain and myocardial tissue. chemotherapeutic resistance of the cell lines.

34 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

65 66 SELECTIVE AND SENSITIVE QUANTIFICATION SIMULTANEOUS DETERMINATION OF OF THE HDAC-INHIBITOR VORINOSTAT PREDNISOLONE AND CICLOSPORINE IN (SAHA) IN PLASMA AND PBMCS BY HPLC SERUM SAMPLES OF PATIENTS WITH LC/MS/ COUPLED TO ELECTROSPRAY TANDEM MASS MS SPECTROMETRY (LC/MS/MS) R. Oertel1, J. Schmitt2 and W. Kirch1 1 L. Liu1, O. Witt2, W. E. Haefeli1 and J. Burhenne1,3 TU Dresden, Institut fu¨r klinische Pharmakologie, Fiedlerstraße 27, 01307 2 1Department of Internal Medicine VI, Clinical Pharmacology and Dresden, TU Dresden, Klinik und Poliklinik fu¨r Dermatologie, Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld Fetscherstraße 74, 01307 Dresden, Germany 410, 69120 Heidelberg, 2Department of Pediatric Oncology, Hematology and Immunology, University of Heidelberg, Im Neuenheimer Feld 430, Introduction In a clinical study patients with atopic dermatitis were 69120 Heidelberg, 3Department of Internal Medicine VI, University of treated with the corticosteroid prednisolone or with the immunosuppressant ciclosporine. Both drugs have considerable adverse effects. Heidelberg, 69120 Heidelberg, Germany Therefore the compliance of the patients should be controlled. Methods and Materials An HPLC method with tandem mass spectrome- Introduction Suberoylanilide hydroxylamic acid (SAHA, Vorinostat) is try has been developed to determine serum concentration of both drugs. the first approved histone deacetylase (HDAC) inhibitor for therapy of The used LC-MS-MS system was a Quattro micro (Micromass, Manchester, leukemia. The relationship between extracellular (plasma) and intracel- GB) equipped with an electrospray interface (ESI). Prednisolone and ci- lular (leukocytes/peripheral blood mononuclear cells (PBMC)) concen- closporine were measured using the multiple reaction monitoring mode tration of SAHA compared to the intracellular HDAC activity altered by (MRM) with the specific transitions between m/z 360 (parent ion) and m/z SAHA is highly of interest. Therefore an LC/MS/MS assay (SAHA plasma 147 for prednisolone and between m/z 1202 (parent ion) and m/z 156.5 and PBMC concentration) and an enzymatic HDAC inhibition assay for ciclosporine. The serum samples were prepared with a simple auto- were developed and applied to ex vivo blood samples incubated with matic solid phase extraction. 500 ll serum mixed with 500 ll formic acid SAHA. (9%) and Oasis-HLB SPE-cartridges were used. The chromatographic sepa- Methods and Materials Fresh whole blood samples from healthy vol- ration was performed on a Synergy 4 l Polar-RP 80A, 150 mm · 2mm unteers were incubated with SAHA at therapeutic concentrations and column. A mobile phase gradient was applied with a mixture of acetoni- HDAC activity was determined enzymatically. The PBMCs were isolated trile, ammonium acetate in water and formic acid. Retention times were via ficoll gradient using BD vacutainer CPT. SAHA was extracted from 3.7 min (prednisolone) and 4.5 min (ciclosporine). plasma and PBMCs by liquid/liquid-extraction using TBME at pH 5.0 Results The coefficient of variation was <15%. For ciclosporine a good lin- and analysed on a Phenomenex Luna C18 column coupled to ESI-MS/ ear response over the range of 1.5 ng/ml to 200 ng/ml was demonstrated. MS in the selected reaction monitoring mode. SAHA was quantified The low limit of quantification of prednisolone was 15 ng/ml. The accu- using the authentic deuterated internal standard and the assay was racy ranged from 85% to 115% of the respective nominal values. validated according to FDA standards. Conclusion The developed method was suitable to control the compli- Results For SAHA quantification in plasma and PBMCs, calibration was ance of the patients. linear in the range of 10 ng/ml--1000 ng/ml and 0.1 ng to 10 ng/cell pellet (~3 · 106 cells). Limits of quantification were 10 ng/ml in plasma and 0.1 ng/cell pellet in PBMCs. Accuracy ranged from 92.1% to 105.0% of nominal values and precision varied between 1.9% to 6.1% CV. The assay fulfilled all recommendations of the FDA guideline concerning accuracy, precision, selectivity, and stability. Conclusion This precise, selective, and sensitive assay allowed monitoring of SAHA in different blood compartments and was successfully applied to ex vivo studies and patients in clinical drug trials.

2009 The Authors 35 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

67 TARGETED STABLE-ISOTOPE DILUTION GC-MS/MS DETERMINATION OF THE ENDOCANNABINOID ANANDAMIDE AND OTHER FATTY ACID ETHANOL AMIDES IN HUMAN PLASMA A. A. Zoerner, F. M. Gutzki, M. T. Suchy, B. Beckmann, S. Engeli, J. Jordan and D. Tsikas Medical School Hannover, Institute of Clinical Pharmacology, Carl-Neuberg-Str. 1, 30625 Hannover, Germany

Introduction Ongoing clinical research projects in our group required a sensitive and specific assay for anandamide (AEA) and other fatty acid ethanol amides (FAEAs) that could cope with small sample volumes. Most currently available data on FAEAs is based on the LC-MS/ MS methodology. We developed a stable-isotope dilution GC-MS/MS method for the quantitative determination of AEA, oleic acid ethanol amide (OEA) and palmitic acid ethanol amide (PEA) in human plasma. Methods and Materials We applied single solvent extraction of FAEAs and their internal standards from plasma (50--1000 ll) with toluene and a two-step derivatization to the pentafluorobenzamide pentaflu- oropropionyl derivatives (FAEA-PFBz-PFP) with pentafluorobenzoyl chloride and pentafluoropropionic anhydride. Then, we simultaneously quantified FAEAs by selected reaction monitoring of the respective fatty acid carboxylate anions produced by collision-induced dissociation (CID) of the parent ions [M -- PFBz]-. Results The present method was fully validated for anandamide. Accu- racy and precision of the method were within the range of 100 ± 20% and less than 20%, respectively, in the concentration range 0--4 nM. Mean overall recovery was 90 ± 3%. The LOQ and LOD values were 0.25 nM of added AEA in plasma samples and 400 amol of injected AEA-PFBz-PFP derivative, respectively. In plasma of 16 healthy individuals plasma AEA concentration was 1.35 ± 0.32 nM. No correlation between plasma AEA concentrations and gender or body mass index was observed. The underlying mechanism during CID was similar for OEA and PEA, their plasma concentration were approximately 10 nM. We also identified stearic acid ethanol amide (SEA), linolenic acid ethanolamide, and linoleic acid ethanol amide in human plasma. A considerable amount of OEA, PEA and SEA may have been released from laboratory materials and was reduced when we applied glass ware. Conclusion We developed a stable-isotope dilution GC-MS/MS method for the quantitative determination of AEA, oleic acid ethanol amide (OEA) and palmitic acid ethanol amide (PEA) in human plasma using their stable-isotope labeled analogs as internal standards. The methodology is straightforward, accurate, precise and highly specific for FAEA.

36 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

PLANNING AND CONDUCTION OF CLINICAL TRIALS

68 69 STUDY DISCONTINUATIONS IN CLINICAL PHARMACOVIGILANCE IN CLINICAL TRIALS TRIALS AND DATA MONITORING AFTER POINT IN TIME OF AUTHORISATION COMMITTEES T. Fischer T. Fischer BfArM, Klinische Pru¨fung, Kurt-Georg-Kiesinger Allee 3, 53175 Bonn, BfArM, Klinische Pru¨fung, Kurt-Georg-Kiesinger Allee 3, 53175 Bonn, Germany Germany Introduction According to the European Directive 2001/20, the spon- Introduction Data Monitoring Committees have been more frequently sor shall ensure that all relevant information about Suspected Serious incorporated in the methodological conduct of clinical trials in the last Unexpected Adverse Reactions (SUSARs) is recorded and reported as years. Corresponding conditions and criteria are described in the Euro- soon as possible to the competent authorities in the Member States pean Guideline EMEA/CHMP/EWP/5872/03 Corr. Based on the submit- and to the Ethics Committee. Based on the submitted SUSARs in the ted clinical trials in the approval procedure, the question should be last five years, the question would be raised, how many safety reports answered, whether a relationship between the integration of a DMC in could be directly linked to one of the authorised clinical trials. the conduct of a clinical trial and the event of permanent termination Methods and Materials In general, the variety of specific situations in of the study could be presumed. each clincial trial cannot be covered by algorithms. Therefore, all submit- Methods and Materials Generally, clinical trials have to be explicitly ted safety reports have to be carefully analysed and allocated to the spe- approved by the national competent authority and the reponsible Ethics cific clinical study. The total number of safety reports, which were Committee after implementation of the Directive 2001/20/EC in national submitted to the German competent authority, was compared to the sub- law. Since the cut date August 6th 2004, 5000 applications of clinical trials mitted clinical trials and their different phases. Furthermore, the number were submitted to the German competent authority until February 5th, of safety reports were matched with the SUSAR criteria of the sponsor. 2009. With the help of a retrospective analysis, the number of stopped Results Since the new legislation came into force on August 6th 2004, studies has been evaluated. Furthermore, the reasons for the study termi- 5000 applications of clinical trials were submitted to the German com- nations have been collected and recorded in a descriptive manner. petent authority until February 5th, 2009. During this time frame, Results From the 5000 approved and practical conducted clinical trials, 1 112 366 safety reports were sent to the Federal Institute for Drugs 134 clinical trials have been stopped -- 96 studies were permanent ter- and Medical Devices. From these reports, 189 843 fulfill the SUSAR cri- minated. Totally, sponsors addressed different reasons for stopping teria from the view of the sponsor. That means an average of 37.97 clinical trials. 32 clinical trials were terminated for safety reasons. A safety reports could be allocated to each clinical trial in order to detect comparison of the study termination with the phase of the clinical safety issues during the conduct of this trial. Many of the safety reports development phase showed a lower termination rate for safety reasons could be found in the early clinical development phase. in the clinical trials of the phase III. Only 5 of the stopped clinical trials Conclusion Based on the submitted safety reports, one of the main for safety reasons had a Data Monitoring Committee. tasks of the competent authorities and ethics committees is to super- Conclusion A relationship between the implementation of the DMC vise the conduct of clinical trials. The sponsors have to identify SUSARs and a permanent termination of studies could not be established. Most from clinical trials for ‘expedited reporting’ to competent authorities of the terminated clinical trials happened in the early clinical develp- and ethics committees. It has to be emphasized that one of the prere- ment phase, whereas Data Monitoring Committees are rarely imple- quisite’s of a ‘true’ SUSAR is a presumed relationship between the IMP mented. Sufficient individual and general criteria for study termination and the Serious Adverse Event (SAE). This main topic should be kept in has been described in the protocol of the terminated clinical trials. mind by the sponsors.

2009 The Authors 37 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

70 71 A SIX-YEARS REVIEW OF INCIDENCE OF COAGULATION DISTURBANCES IN CLINICAL ADVERSE EVENTS IN EARLY PHASE I -- A TRIALS WITH ANTICOAGULANTS -- COMPARISON BETWEEN FIRST-IN-MAN INSUFFICIENT EFFICACY, WELL-KNOWN STUDIES, BIOAVAILABILITY AND/OR FOOD ADVERSE REACTIONS OR ‘SUSAR’S’? AND INTERACTION STUDIES J. Siegert1,2, C. Hillger1,3, U. Gra¨fe1, B. Brecht1, W. Kirch1,2 and 1 I. A. Ighrayeb1,M.Bo¨ttcher1, O. Boix2 and G. Wensing1 C. Schindler 1 1BayerSchering Pharma AG, Pharmacodynamics, Aprather Weg, 42096 TU Dresden, Institut fu¨r Klinische Pharmakologie, Fiedlerstrasse 27, 01307 2 Wuppertal, 2Bayer Schering Pharma AG, Global Pharmacometrics, Dresden, TU Dresden, Ethikkommission, Fiedlerstrasse 27, 01307 Dresden, 3 Aprather Weg, 42096 Wuppertal, Germany Forschungsverbund Public Health Sachsen, Fiedlerstrasse 33, 01307 Dresden, Germany Introduction Recently, we reported the incidence of adverse events (IoAE) in first-in-man (FiM) studies performed at the Bayer in-house unit Introduction In clinical trials investigators have to inform the sponsor Wuppertal between 2000 and 2005 (Bo¨ttcher et al. 2007). This review of the trial immediately concerning all serious adverse events (SAE). evaluates the IoAE of bioavailability and/or food (BV/Food) and drug Thereafter the sponsor has to inform the competent authorities and interaction (DRI) studies with small molecules during the same period concerned ethics committees (EC) within 7 (death, etc.) or 15 days in comparision to FiM studies. about all suspected unsuspected serious adverse reactions (SUSAR). Methods and Materials In total, 86 studies were investigated, 24 FiM Thereby the sponsor needs to monitor and evaluate the incoming SAE studies, 37 BV/Food and 25 DRI studies. 1996 healthy male subjects to extract correctly the SUSARs to report onward to authorities and EC. (aged 18--61 years) were enrolled, receiving 3312 treatment periods Within this task the drug safety department of the sponsor has to dis- (placebo: 416, verum: 2896). All adverse events (AE) were coded tinguish between events (something that happened during the trial according to Medical Dictionary for Regulatory Activities (MedDRA). without a causal relationship with the applied drug(s), e.g. side effects Results No death occurred. Serious adverse events (SAEs) occurred in 12 or events due to the basic illness) and reactions due to the drug(s) (at out of 1996 subjects. Only two cases of hypotension (FiM) were drug- least a causal relationship between the event and the suspected drug related. Out of 1350 treatment emergent AEs, 1213 (89.9%) were mild, is highly likely). Furthermore it has to be distinguished between known 121 (8.9%) moderate and 16 (1.2%) severe. The IoAE per treatment was (reactions listed in investigators brochures or previous SUSAR reports) 0.5 for FiM and DRI, whereas it was 0.27 for BV/Food studies. Indepen- and unexpected reactions. dent from study type and treatment, the most frequent reported treat- Methods and Materials Our ethics committee received vast numbers ment emergent AEs were headache (23.6%) and nasopharyngitis (10%), of SUSAR reports (described as independent unexpected reactions) for which are common and not specific. Flushing (5.1%), nausea (4.1%) and bleeding complications (haemoptysis, gastrointestinal haemorrhage, nasal congestion (3.5%) were frequent AEs which could be explained by bloody urine, brain haemorrhage), and lung embolism, stroke, myocar- the mode of action of cardiovascular test compounds. dial infarction and deep vein thromboses. Conclusion The two drug-related SAEs of hypotension were observed Results Patients treated with anticoagulants e.g. factor 10a inhibitors in FiM, whereas no serious drug-related treatment emergent AE was are usually at risk of thromboembolic complications due to their basic found in BV/Food- and DRI-studies. BV/Food showed the lowest IoAE. illness. Furthermore bleeding complications are a well known risk Irrespective of study type, headache was by far the most frequent (adverse reactions) due to the use of these classes of substances. unspecific AE. Conclusion Thereby the evaluations of drug safety departments of Reference sponsors that such events are unexpected reactions caused by the 1. Bo¨ttcher et al. BCPT 2007; 101: 384. drug use seem not to be conclusive. Furthermore they are in good agreement with earlier independent observations1 that at least 85% of the SUSAR reports sent to ethics committees do not fulfill the legal definitions given for expedited SUSAR reporting. Reference 1. S. Trillenberg, et al. Analysis of SUSAR reports sent to an Ethics Committee, P 9, 10. VKliPha Congress, Berlin, 2008.

38 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

72 73 LEVOFLOXACIN CAN BE USED EFFECTIVELY AS TQT STUDIES: THEIR IMPACT ON DRUG A POSITIVE CONTROL IN THOROUGH QT/QTC DEVELOPMENT AND THE KEY ELEMENTS OF A STUDIES IN HEALTHY VOLUNTEERS SUCCESSFUL TQT STUDY J. Taubel1, A. Naseem1, T. Harada1, R. Arezina1, U. Lorch1 and K. Berelowitz, A. Naseem, U. Lorch, R. Arezina and J. Taubel A. J. Camm2 Richmond Pharmacology Ltd, St George’s University of London, Cranmer 1Richmond Pharmacology Limited, St George’s University of London, Terrace, Tooting, London, SW17 0RE, UK Cranmer Terrace, Tooting, London, SW17 0RE, 2Department of Cardiological Sciences, St George’s University of London, Cranmer Terrace, Introduction Thorough QT/QTc (TQT) studies are an indispensible part Tooting, London, SW17 0RE, UK of the development of new chemical entities (NCE). TQT studies could be conducted at a much earlier stage of development and in any case Introduction The aim of this study is to characterise the effects of lev- more frequently, if a significant reduction in cost based on three key ofloxacin on QT interval in healthy subjects and the most appropriate elements can be achieved: design, conduct and analysis. oral positive control treatments for ICH, E14 QT/QTc studies. Methods and Materials The sophisticated methods for ECG analysis Methods and Materials 64 healthy male and female subjects applied to very large volumes of ECG traces are one of the main rea- (29 ± 7 years) received a single dose of levofloxacin (1000 mg and sons for the associated high costs. Due to the unfavourable signal to 1500 mg) and moxifloxacin (400 mg) or placebo in a 4 period cross- noise ratio, TQT studies often include large numbers of volunteers lar- over design. Digital 12-lead ECGs were recorded in triplicate. Measure- gely to accommodate low ECG quality and/or variability. ment of QT interval was performed automatically with subsequent Results Usually, the clinical unit conducting a TQT study is separate manual onscreen over-reading using electronic callipers. from the ECG laboratory analysing the ECG data. This division is ineffi- Results Mean QTcI was prolonged in subjects receiving moxifloxacin cient in many ways with each vendor seeking the best deal. A solution 400 mg compared with placebo. The largest time-matched difference is to place TQT studies within vendors able to provide both the clinical in QTcI for moxifloxacin compared with placebo was observed to be conduct, ECG analysis and interpretation from under one roof. The key 13.19 msec (mean 95% confidence interval [CI] 11.21, 15.17) at selling point for these suppliers is the ability to provide sufficient and 3.5 hours post-dose. For both levofloxacin 1000 mg and 1500 mg the comparable data with: largest time-matched difference in QTcI compared with placebo was • The inclusion of fewer volunteers. observed at 3.5 hours post-dose (mean [95%]: 4.42 [2.44--6.39] msec in • Coupled with the production of fewer ECG’s. 1000 mg and 7.44 [5.47--9.42] msec in 1500 mg). No subject was found • Coupled with best quality ECG’s. to have a QTc greater than 450 msec during the study. Conclusion Current conduct of TQT studies is expensive due to the Conclusion Both levofloxacin and moxifloxacin can fulfil the criteria for analysis of excessive volumes of ECGs and the separation between clin- a positive comparator. ICH E14 guidelines recommend a threshold of ical units and ECG core laboratories. Additional expenses may arise above 5 msec for a positive QT/QTc study. The largest time-matched from excessive volunteer numbers. This cost can be reduced if TQT difference in QTc for levofloxacin suggests the potential for use in studies are well designed, well conducted and appropriately analysed. more rigorous QT/QTc studies. This study has demonstrated the utility of levofloxacin 1500 mg in confirming assay sensitivity resulting in measuring mean QTc changes around 5 msec.

2009 The Authors 39 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

74 75 THE INNOVATION CRISIS OF THE RANDOMIZED CONTROLLED DOUBLE BLIND PHARMACEUTICAL INDUSTRY WITH A CLINICAL TRIALS VERSUS OPEN TRIALS PARTICULAR EMPHASIS ON GERMANY J. Siegert1, C. Hillger1,2, W. Kirch1 and C. Schindler1 1 K. Grave-Hermann, O. von Richter and R. Hermann TU Dresden, Institut fu¨r Klinische Pharmakologie, Fiedlerstrasse 27, 01307 2 Clinical Research Appliance, Rossittenstraße 15, 78315 Radolfzell, Dresden, Forschungsverbund Public Health Sachsen, Fiedlerstrasse 33, Germany 01307 Dresden, Germany

Introduction Poor R&D-productivity in the pharmaceutical industry Introduction In many cases randomized controlled double blind clini- (PhI) is well acknowledged and has prompted regulatory agencies to cal trials are often regarded as gold standard for clinical trials. A few address their respective concerns in public concept papers [1, 2] The years ago a drug agency requested a double blind clinical trial compar- present survey attempted to investigate PhI-internal factors to poor ing a radiodiagnostic with physiological saline as placebo in a clinical R&D-productivity in Germany. study planned to prove efficacy and safety for a radio-diagnostic. Methods and Materials Cross-sectional, standardized survey (N = 106 Methods and Materials Analyzing the situation it was obvious that a questions/statements) among N = 86 senior R&D representatives of the double blind design would be contra-productive in this setting due to PhI and contract research organizations (CROs) in Germany. Participants the fact that the first image would reveal the iodine content of the anonymously rated their personal agreement or disagreement with diagnostic and would thereby clearly define which injection would each of the statements by using 5-point Likert Scales. have been verum or placebo much earlier than the code break. Results N = 138 questionnaires were dispatched and N = 86 com- Results In other cases the subjects have been able to give a highly pleted (62.3%). Participants confirmed the existence of innovational precise forecast of their treatment group due to specific side effects of deficits in the PhI, with an unfavorable trend seen in Germany as com- the verum, in this case dry mouth. In recently planned clinical trials for pared to international standards. The results cast doubts on the strate- different antidiabetics, blood glucose self-test determinations were gic directions of the German PhI. This was consistent with the scheduled during a double blind phase. In these cases it should be perception of a poor R&D-mindset of upper PhI management. Two expected that the blinded situation could not be kept throughout the thirds of the participants expressed that poor appreciation of the R&D whole trial. Furthermore in clinical trials with radioactive diagnostics or requirements by ‘non-R&D’ board members, and replacement of R&D- therapeutics the radiation dose of the patient (subject) has to be docu- managers by business and marketing people in leading positions are mented by isotope, dose and time distribution not allowing any contributors to poor R&D-productivity. 70% of participants regarded blinded clinical trials. In these trials a bayesian approach might be valu- changes in the corporate culture as major obstacle to innovation. 55% able to limit the number of patients exposed to a radiation. of participants rated that the attractiveness of the PhI as employer has Conclusion In honest considerations it has to be concluded that aside worsened over the last decade, and 50% expressed concern that this randomized, controlled, double blind clinical trials, in some circum- may get worse. 80% of participants agreed that capabilities for innova- stances, open controlled or even open single armed trials are valuable tion of the German PhI are already limited by the availability of quali- tools to prove efficacy and tolerability of drugs. fied R&D personnel, and that this is likely to worsen in the future. Conclusion The survey suggests that the German PhI currently lags behind international R&D-productivity and identified various PhI-internal obstacles to innovation. Thereof, the limited availability of suitably qualified R&D managers and personnel appears to be one of the major concerns. References 1. U.S. Departmernt of Health and Human Services Food and Drug Administraiont. Challenge and Opportunitiy on the Critical Path to New Medical Products. 2004. 2. The Innovative Medicines Initiative. Assessment of Economical and Societal Effects. 2007. http://imi.europa.eu/docs/imi-ia-report-032007_ en.pdf

40 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

FROM BYTES TO BEDSIDE: ELECTRONIC TOOLS FOR DRUG DOSING AND INFORMATION

76 77 DOSE-RELATED REFERENCE RANGES FOR ADHERENCE TO GUIDELINES OF THERAPEUTIC DRUG MONITORING IN ANTITHROMBOTIC TREATMENT OF ATRIAL HUMAN BLOOD SPECIMENS FIBRILLATION AND REASONS FOR GUIDELINE E. Haen VIOLATION Klinik und Poliklinik fu¨r Psychiatrie, Psychosomatik und Psychotherapie K. Schwarz1,K.Mo¨rike1, C. Meisner2, D. Henke2, R. Fux1 der Universita¨t Regensburg, Klinische Pharmakologie, Universita¨tsstr. 84, and C. H. Gleiter1 93053 Regensburg, Germany 1Universita¨tsklinikum Tu¨bingen, Institut fu¨r Experimentelle und Klinische Pharmakologie und Toxikologie, Abteilung Klinische Pharmakologie, Introduction In therapeutic drug monitoring (TDM) drug concentra- Otfried-Mu¨ller-Str. 45, 72076 Tu¨bingen, 2Universita¨tsklinikum Tu¨bingen, tions should not be returned to the sender just as a plain value, they 1 Institut fu¨r Medizinische Biometrie, Westbahnhofstrasse 55, 72070 should be accompanied by a clinical pharmacological comment. Tu¨bingen, Germany Methods and Materials An internet-based, computer programme is described that allows to organize the laboratory handling of TDM spec- Introduction Objectives To improve guideline adherence in anti- imens and their clinical pharmacological comments. thrombotic therapy of atrial fibrillation (AFib) patients and to identify Results Drug concentrations are related to both the literature known reasons for guideline violation. Although randomised trials have estab- therapeutic reference range and the newly defined dose related refer- lished the benefit of antithrombotic prophylaxis for stroke prevention ence range. The dose related reference range is calculated as a concen- in patients with AFib, several observational studies have shown subop- tration range within that a drug concentration has to be expected timal use. The efficacy of interventions to improve adherence to guide- under medication with a given dose of the drug. The calculation is lines is unknown. based on the direct correlation of the drug dose De (constant dose Methods and Materials A computer-based treatment algorithm (CBA), under long term therapy) to its blood concentration c with the total as a decision aid for the physician, was developed on the basis of the clearance of the drug (Clt) being the correlation coefficient (De = D/ ACC/AHA/ESC 2006 AFib guideline. Office-based physicians located in t=c· Clt). The clearance is taken as arithmetic mean ± standard devi- similar regions of Su¨dbaden (control cohort, C) and Su¨dwu¨rttemberg (2 ation from phase II clinical trials. Thus the dose related reference range intervention cohorts, A and B) enrolled AFib patients and submitted will statistically contain 68.27% of all the drug concentrations deter- data on health and treatment. The study centre analyzed adherence to mined under normal condition in the blood of a normal patient, where the guidelines and, if applicable, reasons for violation. Group A and B ‘normal’ is defined as the patient population in the respective phase II then received education, and group A also received the CBA. Re-analy- clinical trial. It usually consists of patients 18--65 years of age without sis of these items was performed six months later. relevant comorbidity, comedication, and genetic abnormalities in drug Results Fifty-six office-based physicians enrolled 315 AFib patients. metabolism. Therefore, any drug concentration determined outside its Guideline adherence in the first and second analysis in the groups was dose-related reference range creates a signal to alert for individual 61.9% and 58.5% (C), 69.1% and 63.9% (A), 65.0% and 72.0% (B), abnormalities in a patient such as drug--drug-interactions, gene poly- respectively. No change reached statistical significance. As main rea- morphisms that give rise to slow/rapid metabolizers, altered function sons for guideline violation for all groups in the first and second analy- of the excretion organs liver and kidneys by age and/or disease, com- sis we identified deviating choice (24.8%, 20.6%) or performance pliance problems, a missing pharmacokinetic steady state and even (69.5%, 70.1%) of antithrombotic therapy and contraindications (11.4%, signal overlay in the laboratory analysis. 12.4%). Conclusion The computer programme is a necessary tool to present Conclusion The use of the current CBA was not associated with all the information contained in the blood concentration of a drug. A improved guideline adherence. If however, identified reasons for guide- table listing factors that allows the calculation of dose-related reference line violation will be included into an advanced CBA, improvement ranges for all relevant psychopharmaca will be included in the first may be possible in the future. update of the AGNP TDM consensus guideline. Acknowledgements Supported by Bundesa¨rztekammer, Projekt zur Reference Fo¨rderung der Versorgungsforschung (Projekt-Nr. 06-36). 1. Baumann P, Hiemke C, Ulrich S et al. (2004). The AGNP-TDM expert group consensus guidelines: therapeutic drug monitoring in psychia- try. Pharmacopsychiatry 37: 243--265.

2009 The Authors 41 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

78 79 THE NEWLY DEVELOPED COMPUTERIZED A THRESHOLD VALUE TO INCREASE THE DECISION SUPPORT SYSTEM AIDPAINCARE CLINICAL RELEVANCE OF OVERDOSE ALERTS IMPROVES GUIDELINE ADHERENCE IN H. M. Seidling1,2, C. Senger1, J. Szymanski3, T. Bertsche1,2, J. Kaltschmidt1, S. Schmiedl3, P. A. Thu¨rmann3, K. Farker4, TUMOUR PAIN THERAPY 5 6 7 8 1,2 3 3 2 B. Drewelow , M. Hippius , W. Siegmund , J. Hasford and T. Bertsche , V. Askoxylakis , G. Habl , F. Laidig , 1,2 1 1 4 W. E. Haefeli J. Kaltschmidt , S. P. W. Schmitt , H. Ghaderi , 1 Department of Internal Medicine VI, Clinical Pharmacology and A. Zabel-du Bois3, S. Milker-Zabel3, J. Debus3, H. J. Bardenheuer4 Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld and W. E. Haefeli1,2 410, 69120 Heidelberg, 2Cooperation Unit Clinical Pharmacy, University of 1Department of Internal Medicine VI, Clinical Pharmacology and Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, 3Philipp Klee Pharmacoepidemiology, University of Heidelberg, INF 410, 69120 Institute of Clinical Pharmacology, University of Witten/Herdecke, Heidelberg, 2University of Heidelberg, Cooperation Unit Clinical Pharmacy, Heusnerstraße 40, 42283 Wuppertal, 4Regional Pharmacovigilance Center INF 410, 69120 Heidelberg, 3Department of Radiation Oncology, University Weimar, Institute of Clinical Pharmacology, University of Jena, Dornburger of Heidelberg, INF 400, 69120 Heidelberg, 4Department of Straße 159, 07740 Jena, 5Regional Pharmacovigilance Center Rostock, Anaesthesiology, University of Heidelberg, INF 131, 69120 Heidelberg, Institute of Clinical Pharmacology, University of Rostock, Schillingallee 70, Germany 18057 Rostock, 6Regional Pharmacovigilance Center Jena, Institute of Clinical Pharmacology, University of Jena, Dornburger Strasse 159, 07740 Introduction Although numerous pharmacological options are avail- 7 able, tumour pain is often not appropriately treated and guidelines are Jena, Regional Pharmacovigilance Center Greifswald, Institute of Clinical not followed. To facilitate individualised tumour pain treatment, an Pharmacology, University of Greifswald, Freidrich-Loeffler-Str. 23d, 17487 8 algorithm-based computerised decision support system (AiDPainCare) Greifswald, Pharmacovigilance Center for Method Development and was developed by a multidisciplinary expert panel. Data Processing, Institute of Medical Informatics, Biometry and Methods and Materials In a prospective controlled cohort study Epidemiology, University of Munich, Marchioninistr. 15, 81377 Munich, (n = 50 patients per group) a daily pain assessment was conducted fol- Germany lowed by a pain therapy counseling of clinicians by clinical pharmacol- ogists/pharmacists based on recommendations generated by Introduction The success of electronic alerting systems depends on AiDPainCare. Adherence to international guidelines was assessed as the clinical relevance of presented warnings. Appropriate warnings for the primary outcome. Secondary outcomes were pain relief using the excessive dosage therefore require consideration of patient characteris- numeric visual analog scale (NVAS) at rest and during physical activity, tics to correctly personalise the upper dose limit (iMRTD). The specific- co-analgesic prescription, and acceptance rates of recommendations. ity can further be enhanced by definition of threshold values above Results At discharge, the number of patients with at least one devia- which overdosage correlates with clinical endpoints. tion from guidelines decreased from 74% in controls to 14% in the Methods and Materials To evaluate the potential correlation of a intervention group (P < 0.001), while on admission the prevalence was threshold factor with clinical outcome, a cohort of patients on cardiac similar (80% versus 84%, P = 0.60). In the intervention group, pain glycosides (CG) who were admitted to hospital due to an adverse drug assessed by NVAS decreased at rest from 3 (Q25%--Q75%: 2--5) on reaction (documented by the Network of Regional Pharmacovigilance admission to 1.5 (1--2) at discharge (P < 0.01) and during physical activ- Centers, NRPC, supported by BfArM Project No.: Fo 2.1-68502-201) was ity from 7 (5--9) to 2.5 (1--5; P < 0.001). The number of patients treated analysed. Patients were classified in those admitted due to dose- with co-analgesics at discharge increased from 46% patients in controls dependent CG-toxicity and those admitted due to other drug toxicity to 66% in the intervention group (P = 0.04) starting from a similar (control group). Optimum threshold values were calculated by ROC- prevalence on admission (42% versus 54%, P = 0.23). Of 279 issued rec- analysis with a desired specificity >80%. ommendations 85% were fully accepted by the physicians. Results A randomly selected dataset of the NRPC (2000--2005) included Conclusion Guidelines for tumour pain therapy were frequently not 411 patients with CG (mean age: 76.8 ± 9.6 years; 66% female). In 138 followed. An intervention based on AiDPainCare increased adherence cases (34%), hospital admission resulted from dose-dependent CG-toxic- to guidelines. ity with mean CG dosage = 1.14 ± 0.29-fold iMRTD. Mean CG dosage in patients whose admission was not caused by CG-toxicity was significantly lower (1.03 ± 0.42-fold iMRTD; t-test P < 0.001). The cut-off value to maximise sensitivity and specificity was 1.05 (sensitivity = 67%, specificity = 62%). Exclusion of patients with co-medication modulating CG- toxicity (e.g. antiarrhythmics) further enlarged the group differences (1.26 ± 0.25-fold iMRTD versus 0.99 ± 0.4-fold). The respective cut-off value to achieve a specificity = 80% was 1.15 (sensitivity = 63%). Conclusion A threshold value requires careful adaption for distinct substances. In critical dose drugs, the value might be even below standard bioequivalence ranges.

42 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

80 81 MODULATORS FOR ELECTRONIC RISK IMPACT OF ELECTRONIC DECISION SUPPORT PREDICTION OF ADVERSE DRUG EVENTS -- FOR ECONOMIC PRESCRIBING IN A HOSPITAL PATIENT CHARACTERISTICS IN DRUG--DRUG PROVIDING TERTIARY CARE INTERACTIONS AND DOSE ADJUSTMENTS M. G. Pruszydlo, C. Senger, J. Kaltschmidt and W. E. Haefeli C. Senger1, H. M. Seidling1,2, S. P. W. Schmitt1, T. Bertsche1,2, Department of Internal Medicine VI, Clinical Pharmacology and J. Szymanski3, S. Schmiedl3, M. Rottenkolber4, J. Kaltschmidt1, Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld B. Drewelow5, W. Siegmund6, M. Hippius7, K. Farker8, 410, 69120 Heidelberg, Germany J. Hasford4, P. A. Thu¨rmann3 and W. E. Haefeli1 1Department of Internal Medicine VI, Clinical Pharmacology and Introduction According to legal and economic requirements pre- Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld scribed drugs are often switched in German pharmacies to less expen- 410, 69120 Heidelberg, 2Cooperation Unit Clinical Pharmacy, University of sive pharmaceutical equivalences or drugs regulated in drug discount 3 contracts. To avoid later switches the computerised physician order Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, HELIOS Clinic Wuppertal, Philipp-Klee Institute of Clinical Pharmacology, University entry system (CPOE) of the University Hospital Heidelberg (AiDKlinik ) suggests but does not enforce prescription of available drug alterna- Witten/Herdecke, Witten/Herdecke, 4Institute of Medical Informatics, tives during the prescription process. In our study we investigated pre- Biometry and Epidemiology, Ludwig-Maximilians-University Muenchen, scribers’ acceptance of this computerised decision support (CDS). Munich, 5Regional Pharmacovigilance Center Rostock, Institute of Clinical Methods and Materials For every drug in the CPOE users can search Pharmacology, University of Rostock, Rostock, 6Regional and display available pharmaceutical equivalences. Over 15 weeks we Pharmacovigilance Center Greifswald, Institute of Clinical Pharmacology, analysed in >18 000 consecutive prescription processes whether the 7 University of Greifswald, Greifswald, Regional Pharmacovigilance Center primarily sought drugs were prescribed or alternative products subse- Jena, Institute of Clinical Pharmacology, University of Jena, Jena, quently suggested by the CPOE/CDS. After a nine-week data collection 8 Regional Pharmacovigilance Center Weimar, Institute of Clinical period (T1) we sent an email newsletter to all hospital employees to Pharmacology, University of Jena, Jena, Germany emphasise the importance of economic prescribing and communicate the available CDS, followed by another six-week data collection period Introduction A significant fraction of adverse drug reactions (ADR) is (T2). triggered by excessive drug concentrations caused by excessive doses, Results In T1 27 476 and in T2 17 924 drugs were prescribed. For impaired elimination, or drug-drug interactions (DDI). In addition, 68.4% (T1) and 66.2% (T2) of the prescribed drugs cheaper or discount patient characteristics (e.g. hypokalaemia, weight) may modulate the contract regulated alternatives were available. The percentage of drugs occurrence of ADR. Consideration of these factors may help to tune selected from additionally suggested substitutes increased by 32% the specificity of computerised clinical decision support systems from 0.98% in T1 to 1.29% in T2 (P = 0.002, chi square-test). (CCDSS) for ADR prevention. Conclusion The CDS for searching substitute drugs for economic rea- Methods and Materials We developed a CCDSS for the detection of sons is not well used in a tertiary care hospital. To inform prescribers excessive drug exposure and tested its algorithm, which considered that this indeed could avoid later drug switches in pharmacies DDI and patient characteristics as modulators of dose requirements. In achieved significant effects, however, economic aspects of pharmaco- a cohort of 2250 patients (median age = 72, 69.5% female) admitted therapy after discharge are still widely neglected. Therefore further to a hospital because of confirmed ADR we then assessed how often interventions are planned. individual modulators were present. Results In prescriptions of 95.6% of all patients we found at least one drug mainly excreted renally (Q0 < 0.5), which required age, gender, body weight (BW), and serum creatinine to estimate individual renal function. Moreover, the medication of 59.5% of the patients was con- traindicated at certain degrees of renal impairment. Estimation of dose requirements needed BW and height for 90 respectively five patients. For 29.4% of all patients the algorithm predicted major DDI. Consider- ing potassium levels for 11 possible DDI, the number of patients with major DDI was reduced to 19.0%. Conclusion CCDSS assessing dose requirements is strongly influenced by renal elimination fractions of drugs. Age, gender, BW, height, and serum creatinine levels are therefore needed for the majority of patients. Lab values (e.g. potassium) may help reduce over-alerting in major DDI by one third.

2009 The Authors 43 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

82 83 EVALUATION OF MEDICATION SAFETY IN PHYNX: AN OPEN SOURCE SOFTWARE MEDICAL INPATIENTS WITH THREE DIFFERENT SOLUTION SUPPORTING WEB-BASED PRESCRIPTION SUPPORT SOLUTIONS PATIENT-LEVEL DATA REVIEW FOR DRUG D. Fritz, A. Ceschi, I. Curkovic, M. Huber, M. Egbring, SAFETY DATABASE STUDIES G. A. Kullak-Ublick and S. Russmann M. Egbring, G. A. Kullak-Ublick and S. Russmann Universita¨tsspital Zu¨rich, Klinische Pharmakologie und Toxikologie, Universita¨tsspital Zu¨rich, Klinische Pharmakologie und Toxikologie, Ra¨mistrasse 100, 8091 Zu¨rich, Switzerland Ra¨mistrasse 100, 8091 Zu¨rich, Switzerland

Introduction Electronic prescribing and prescription support software Introduction Validation of patient-level information from automated (PSS) provide new opportunities for the evaluation and prevention of medical databases in its clinical context is a key process for drug safety medication errors (ME). We aimed to (i) identify and quantify ME in studies. This concerns initial signal evaluation in pharmacovigilance as medical inpatients, (ii) evaluate and compare the performance of differ- well as formal pharmacoepidemiological studies. ent PSS in detecting ME. Methods and Materials We used the open source software Talend Methods and Materials Prospective cross-sectional analysis of current Open Studio, MySQL Server, MySQL Connector, Java SE, Eclipse, Apache prescriptions in medical inpatients of a tertiary care hospital. We identi- Tomcat and Adobe Flex 3 to build a system named Phynx that sup- fied drug interactions using the PSS TheraOpt, Micromedex Drug-Reax ports data management, and Web-based display and review of patient- and Pharmavista. Pharmavista only checks interactions for up to eight level information in the individual clinical context. This system was concomitantly used drugs. TheraOpt also generates dose adjustment applied to and tested with a dataset containing the complete informa- alerts based on individual age and renal function. The generated alerts tion of 46 501 patients from the UK General Practice Research Data- were evaluated by expert discussion followed by recommendations base (GPRD). when considered appropriate. Results Three separate fields are displayed simultaneously in one Results We studied 100 patients with a median of eight concomitant browser window: (i) Patient index from where individual patients can drugs. The total number of interactions in all patients and number for be selected for display of their detailed profile; (ii) Detailed patient pro- each severity grade (severe/moderate/mild) according to each PSS files showing all information for a selected patient in chronological were as follows: TheraOpt 326 (9/104/213), Drug-Reax 362 (91/248/23), order and with color markings according to the nature of the informa- Pharmavista 53 (0/17/36). TheraOpt further recommended 31 dose tion; (iii) Interactive reviewer field allowing external experts to save adjustments and generated 221 additional warnings. Among all auto- evaluations and comments via a common Web browser. Additional fea- matically generated alerts 34 interactions, two dose alerts and eight tures include color-coding of patients in the index according to their additional warnings were considered as justified and sufficiently rele- review status and blinding of selected information such as drug expo- vant to recommend prescription changes. We found two additional ME sure if necessary. Because we pre-generated patient profiles as XML not detected by any PSS. Altogether 46 recommendations for medica- objects and stored them on a server, the time to display a complete tion changes were actually followed in 23 instances. patient profile for the user in a standard environment was less than Conclusion PSS can sensitively detect ME, but there are major differ- one second after selection from the patient index. Time to review the ences in their functions and severity grading. Only a small proportion complete medical information of one patient with a longitudinal fol- of all alerts were evaluated as clinically relevant. Lack of scientific evi- low-up time of 5 to 10 years is approximately 5 min. dence in complex individual patient care and common off-label use Conclusion Phynx provides a flexible solution for patient-level review remain major challenges for PSS. The studied systems have great of electronic medical information from databases considering the indi- potential to reduce ME in clinical practice, but irrelevant alerts are fre- vidual clinical context. Access times are short, and the displayed infor- quent and should be reduced. mation is structured in chronological order and visually attractive. Phynx can therefore make an important contribution to an efficient use of electronic medical information for signal evaluation in pharmacovigilance as well as for formal pharmacoepidemiological studies.

44 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

84 FINDING WITHOUT SEARCHING: REAL-TIME ANNOTATION OF DRUG INFORMATION IN WEB DOCUMENTS M. Metzner, C. Senger, J. Kaltschmidt and W. E. Haefeli Department of Internal Medicine VI, Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany

Introduction Internet documents with medical content often contain active ingredients or brand names of drugs. For readers not familiar with the drugs it will be helpful to have immediate access to detailed information on those drugs without extra database searches or consultation of books. Methods and Materials We developed a software module able to identify drug-related terms (brand names, manufacturers, strength, and active ingredients) in web documents and to weight their combinations to link it to the most appropriate brand or drug class available in the German market. Optimum allocation of brands was tested using rule-based assignment of scores to word categories and statistical learning. The application was embedded in a clinical network environment to analyze occurring web traffic in real-time. Drug-related terms identified in documents were labelled with hyperlinks leading to comprehensive, up-to-date drug information. Results The system was successfully developed, linked to the internet, and integrated into a hospital intranet. In a 20 000 randomly generated test cases 65% were correctly and rapidly assigned. If up to 5 brands with similar scores were offered, this value increased to 80% using the rule-based approach. The results of statistical learning were significantly better (76% and 91%). Applicability to internet documents was confirmed with high user acceptance. Conclusion Up to nine in ten drug names mentioned in internet documents can be linked in real-time to a drug information system, thus facilitating immediate search for detailed information without changing media.

2009 The Authors 45 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

DRUG INFORMATION

85 86 IS THE ADVERSE REACTION SECTION IN PATIENTS‘ PREFERENCES FOR WRITTEN SPECIFIC PRODUCT CHARACTERISTICS OF INFORMATION ABOUT EFFECTS AND NEWLY APPROVED DRUGS A MIRROR OF UNDESIRABLE SIDE EFFECTS OF DRUGS INADEQUATE SUSAR REPORTING? V. Mu¨lders1,2, O. Herber3, S. Wilm3, D. Schwappach4 and 1,2 J. Siegert, C. Schindler, J. Schro¨der, B. Brecht and W. Kirch P. A. Thu¨rmann 1 TU Dresden, Institut fu¨r Klinische Pharmakologie, Fiedlerstrasse 27, 01307 HELIOS Klinikum Wuppertal, Philipp Klee-Institut fu¨r Klinische 2 Dresden, Germany Pharmakologie, Heusnerstraße 40, D-42283 Wuppertal, Private Universita¨t Witten/Herdecke gGmbH, Institut fu¨r Klinische Pharmakologie, 3 Introduction The basis for the posology and adverse reaction sections Alfred Herrhausen-Straße 50, D-58448 Witten, Private Universita¨t Witten/ of specific product characteristics (SPCs) of newly developed drugs are Herdecke gGmbH, Institut fu¨r Allgemeinmedizin und Familienmedizin, the results of the clinical trials conducted during clinical development Alfred Herrhausen-Straße 50, 58448 Witten, Germany 4Stiftung fu¨r of the corresponding substance. Earlier independent observations1 Patientensicherheit, Asylstraße 77, CH-8032 Zu¨rich, Switzerland revealed that at least 85% of the SUSAR reports sent to ethics committees do not fulfill the legal definitions given for expedited SUSAR Introduction Package information leaflets (PILs) are often perceived as reporting. In the majority of cases either events related to the underly- too long, deterrent and difficult to understand by patients. We thus ing disease or well known adverse reactions have been reported. investigated (i) which information patients desire about their drugs, (ii) Methods and Materials To prove the quality of the adverse reaction how this information should be presented, and (iii) how specifically sections of SPCs these chapters were analyzed in the SPCs of Lenalido- designed brochures affect satisfaction and self-reported compliance. mid (Revlemid) and Bortezomib (Velcade) and compared with data Methods and Materials We conducted six focus groups with n =5--8 known for SUSAR reporting. patients with diabetes mellitus, arterial hypertension and hypercho- Results In both adverse reaction sections of the SPCs many well lesteremia to elicit their wishes for written medicine information. Out known reactions well described to be part of the basic illness are of the interview data attributes (e.g. prevalence of side effects) and reported. In one case the few adverse reactions that have been more their corresponding levels (e.g. graphical versus numerical description prominent compared to the standard treatment were marked with an of prevalence) were derived by content analysis in a multidisciplinary asterisk in the ending up with only a few asterisks in a long list. team and will be used in a stated-preference technique in 1000 people Conclusion Thereby the evaluations of drug safety departments of aged 50 years and above in order to identify the relative importance sponsors, that such events are unexpected reactions caused by the of these attributes. In a subsequent randomised controlled trial with drug used, seem not to be conclusive and are furthermore carried over 420 patients the impact of a specifically designed drug information into the SPCs. Thereby the SPCs of newly developed drugs contain brochure on patients‘ knowledge, satisfaction and self-reported compli- often information that is not specific for the drug used but close to an ance will be evaluated. exhaustive description of the diseases complication. Results Focus groups revealed that PILs cause emotional reactions This situation requires streamlining the SUSAR reporting to obtain valu- such as anxiety, uncertainty or dissatisfaction in patients resulting in a able safety information for new drugs in the SPC. broad spectrum of reactions, ranging from seeking for help to non- Reference compliance. Patients demand readable, attractive and short PILs writ- 1. S. Trillenberg, et al. Analysis of SUSAR reports sent to an Ethics ten in simple language with an accentuation of important information Committee, P 9, 10. VKliPha Congress, Berlin, 2008. by colour or typeface. Modern media such as CDs were requested as well. Conclusion Most existing PILs do not satisfy patients’ needs for useful and understandable information about their drugs. Acknowledgements Funded by the Federal Ministry of Education and Research (01GX0751).

46 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

87 88 DRUGS BEHIND THE WHEEL -- WHY SCORED TABLETS: FACILITATED ESPECIALLY ELDERLY PEOPLE ARE AT RISK SWALLOWING OR FRACTIONAL DOSING? M. Kosa, J. Schro¨der, S. Lochner, L. Goltz and W. Kirch I. Arnet and K. Hersberger Institut fu¨r Klinische Pharmakologie, Medizinische Fakulta¨t, Fiedlerstraße Insitut fu¨r Klinische Pharmazie, Pharmaceutical Care Research Group, 27, 01307 Dresden, Germany Pharmazentrum, Klingelbergstr. 50, 4056 Basel, Switzerland

Introduction According to estimations, up to 15% of all car drivers Introduction The presence of a score-line on a tablet is broadly inter- regularly take drugs. Especially elderly people have a higher risk. On preted as the tacit permission to fractionate the dose. If so, the frag- the one hand they often need a number of drugs, while on the other ments should comply with the content or mass uniformity hand, they often continue driving cars. The following drug classes are requirements of the European Pharmacopoeia. For health professionals, known to influence the driving ability: analgesics, antidiabetics, antihy- information on divisibility is expected to be listed in the Summary of pertensives, ophthalmologicals, ataractics, antiepileptics, antihistamines Product Characteristics (SPC), the Package Leaflets (PL) or in Hospital and muscle relaxants. Drug Formularies. Methods and Materials The medications of patients over 65 years, Methods and Materials We selected the tablets specified as ‘scored’ who contacted the drug information service at the Institute of Clinical in the Swiss Compendium Online by 23rd October 2008 and in the cur- Pharmacology in Dresden, Germany, in 2008, were recorded in a rela- rent Drug Formulary of the University Hospital Basel dated 8th Febru- tional database. Several drug classes, which are known to influence the ary 2008 and screened the corresponding SPCs and PLs for information driving ability, were sorted by ATC-Codes. In the present evaluation, all on divisibility and fractional dosing. Missing data was obtained from medications related to these drug classes were analyzed descriptively. the marketing authorization holders. Results A total of 1457 persons contacted the service in 2008, 554 of Results The Compendium contained 698 different scored tablets them were older than 65 years. Altogether, 458 of 554 (82.7%) patients whose SPCs explicitly mentioned the possibility of fractional dosing for took at least one drug of the mentioned drug classes. Women used 43.8% of them. The Hospital Drug Formulary indexed 188 items as these drugs more frequently (58.1%) than men. Polymedication was scored tablets. The corresponding SPCs mentioned fractional dosing noticed for 65.2%. for 107/188 (56.9%) and a sentence prohibiting it for 5/188 (2.7%). A Conclusion The present evaluation proves that elderly people often fractional dosing according to manufacturers’ answers was permitted take drugs that influence the driving ability. In order to reduce traffic for 49 (26%) of the remaining tablets and was prohibited for 19 accidents caused by the usage of drugs, preventive measures could be (10.1%) of them. Lack of dosage uniformity within the tablet fragments effective. A detailed summary of product characteristics including criti- or presence of ‘historic decorative’ score-lines were the evoked reasons cal phases during the drug therapy may help physicians and pharma- for the interdiction. cists to assess the consequence on roadworthiness. Furthermore a Conclusion For the majority of scored tablets, an explicit statement on consistent labelling, e.g. by an optical symbol could help to identify fractional dosing is not available in the official drug information. Sen- these drugs. tences noting interdiction in the SPCs are easily overlooked. The simple notation ‘divisible’ in the Hospital Drug Formulary is misleading into a prohibited fractional dosing for 12.8% of the indexed scored-tablets.

2009 The Authors 47 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

89 90 GERMAN HEALTH CARE SYSTEM -- UNMET ACCEPTATION OF A DRUG INFORMATION PATIENT INFORMATION NEEDS SERVICE -- A PATIENT EVALUATION J. Schro¨der, L. Goltz, S. Lochner, M. Kosa, C. Stumpe L. Goltz, J. Schro¨der, M. Kosa and W. Kirch and W. Kirch Institut fu¨r Klinische Pharmakologie, Medizinische Fakulta¨t, Fiedlerstraße Institut fu¨r Klinische Pharmakologie, Medizinische Fakulta¨t, Fiedlerstraße 27, 01307 Dresden, Germany 27, 01307 Dresden, Germany Introduction The Institute of Clinical Pharmacology at the TU Dresden Introduction In Germany, several health care reforms were introduced offers a drug information service for members of the AOK Plus health during the past five years to realize cost-containment. Patients often insurance (Allgemeine Ortskrankenkasse). The service takes care of all have problems to understand the legal regulations. Especially the drug drug-related questions and seeks to provide independent and evi- reimbursement system is very complex. The drug information service dence-based information to enhance patient competence. for patients in Dresden noticed a growing number of requests con- Methods and Materials In 2008, 151 patients participated in an evalu- cerning legal issues. ation of the consultation by means of a questionnaire which was sent Methods and Materials The patients contacting the service were to them approximately four weeks after the consultation. The ques- interviewed with regard to their age, gender, reason for enquiry, num- tions to be answered concerned patient satisfaction and confidence, ber and kind of drugs taken, and diseases. The data were recorded in personal benefits from the consultation, state of health, the realization a relational database. All enquiries from January 2008 to December of recommendations and effects on the patient-physician relationship. 2008 were evaluated descriptively with a focus on legal requests. Results 94% of the respondents were satisfied or very satisfied with Results In the evaluated period 1457 persons contacted the service. the advice given, 89% reckoned that their personal benefit was high or 195 (13.4%) of them asked questions about legal regulations. The most very high. Although patient apprehensions were discussed in 77% of common reasons for legal questions were drugs exceeding the refer- all cases, full realization of the given advice occurred only with 37% of ence price (18.5%), medication changes due to contracts between the patients. 65% did not name any reason for this. The patient-physi- health insurances and any companies (11.8%), and reimbursement of cian relationship was in most cases unchanged (74%), or was even over-the-counter drugs (11.8%). A total of 186 drugs were specified, strengthened (10%) while 68% of the respondents felt more confident the leading drugs among these being Nebivolol, Esomeprazole and in handling their medication. 71% stated that the consultation by Atorvastatin. phone could not replace a physician consultation, but 93% would con- Conclusion The drug information service for patients has been tact the drug information service again if they had a question. approached with manifold subjects regarding legal issues. It appears Conclusion Essential goals of the drug information service for patients that many uncertainties exist about the legal situation in the German have been accomplished. The questioned patients felt more confident health care system which frequently need clarification. regarding their medication while patient-physician relationships were scarcely affected, which affirms that the consultation provides assistance but does not intervene with physicians decisions. However, further analysis about the realization of recommendations would be desirable.

48 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

91 FOOD SUPPLEMENTS FOR EYE DISEASES -- AN ANALYSIS OF PATIENT REQUESTS C. Stumpe, J. Schro¨der, L. Goltz and W. Kirch Institut fu¨r Klinische Pharmakologie, Medizinische Fakulta¨t, Fiedlerstraße 27, 01307 Dresden, Germany

Introduction Patients regularly turn to the independent drug information service to find out about the effects of food supplements which were recommended to them by ophthalmologists. Because food supplements are not classified as drugs they usually do not come with a patient information leaflet. This is why many patients have apprehensions about missing indication specifications and therefore doubt the effectiveness. Methods and Materials The patients who used the service were interviewed concerning their socio-demographic characteristics, reason for enquiry, number and kind of food supplements taken, and diseases. In the present evaluation, all enquiries from January 2008 to May 2009 were analyzed descriptively with a main focus on food supplements recommended by ophthalmologists. Results In the evaluated period thirteen patients took food supplements which were recommended or sold to them by ophthalmologists. These supplements contained Lutein, Zeaxanthin, Vitamin C, Vitamin E, Beta carotene and Zinc in different compositions. The patients were between 54 and 90 years-old, and mostly (62%) feminine. Information need about the benefit of food supplements after a cataract operation was the most common reason for an enquiry (38%), followed by questions about using them with a macular degeneration (31%) or arterial occlusive diseases of the eye (15%). Conclusion Many patients feel unassured about food supplements, because the ophthalmologists advice is usually not confirmed by a patient information leaflet. There is a need for awareness raising by physicians as well as pharmacists keeping in mind that the state of evidence is in many cases weak.

2009 The Authors 49 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

QUALITY CONTROL AND PATIENT SAFETY

92 93 ADVERSE DRUG REACTIONS: THE MOST INCONSISTENT USE OF PROTON PUMP COMMONLY INVOLVED DRUGS AND ORGAN INHIBITOR PROPHYLAXIS FOR PREVENTION SYSTEMS IN PHARMACOVIGILANCE REPORTS OF NON-STEROIDAL ANTI-INFLAMMATORY AT THE UNIVERSITY HOSPITAL ZURICH DRUG-INDUCED GASTROINTESTINAL A. Ceschi1, K. Ingram1, I. Curkovic1, M. Egbring1, D. Fritz1, DAMAGE (NSAID GID) IN HIGH RISK N. Corti1, A. Jetter1, S. Russmann1, W. Kirch1,2, 1 1,2 PATIENTS G. A. Kullak-Ublick and M. Huber 1 1 2 3 1 G. Haase ,S.C.Mu¨ller , P. A. Thu¨rmann , M. Rottenkolber Division of Clinical Pharmacology and Toxicology, Department of and B. Drewelow1 Internal Medicine, University Hospital Zurich, Ra¨mistrasse 100, 8091 1Universita¨t Rostock, Institut fu¨r Klinische Pharmakologie, PVZ Rostock, Zurich, Switzerland, 2Technische Universita¨t Dresden, Institute of Clinical Schillingallee 70, 18057 Rostock, 2HELIOS Klinikum Wuppertal, Philipp Pharmacology, Faculty of Medicine, Fiedlerstraße, 01307 Dresden, Klee-Institut fu¨r Klinische Pharmakologie, Heusnerstr. 40, 42283 Wuppertal, Germany, 3Ludwig-Maximilians-Universita¨tMu¨nchen, Institut fu¨r Medizinische Informationsverarbeitung, Biomtrie und Epidemiologie, 81377 Mu¨nchen, Introduction Pharmacovigilance is essential to improve drug safety. The Division of Clinical Pharmacology and Toxicology at the University Germany Hospital Zurich is one of six Swiss academic pharmacovigilance centres. The evaluation of reports of adverse drug reactions (ADR) in collabora- Introduction Gastrointestinal toxicity is a common adverse effect of tion with the national drug authority Swissmedic (Swiss Agency for NSAIDs and COX-2-inhibitors. PPI co-therapy has been shown to reduce Therapeutic Products) and WHO Monitoring Centre in Uppsala, Swe- the incidence of dyspepsia in those taking NSAIDs. Particularly patients den, is a key task of our division1. at risk should receive prevention therapies with PPI. Risk factors for Methods and Materials We evaluated all spontaneous ADR reports NSAID-related gastric injury include age >65 years, history of ulcer dis- processed by our division between January 2008 and June 2009. ADRs ease, use of multiple agents (e.g., ‡2 NSAIDs, or an NSAID plus aspirin were classified according to ICD-10 (International Statistical Classifica- -- even at cardioprotective doses), high doses of an NSAID, and concur- tion of Diseases and Related Health Problems 10th Revision, Version rent use of corticosteroids or anticoagulants1, infection with Helicob- 2009). acter pylori or smoking. Results In the analysed period, we assessed and forwarded 692 ADR Methods and Materials All nonelective admissions to departments of reports. 42.5% of all reports originated from hospitals. The most com- internal medicine in the two urban hospitals of Rostock were screened mon drugs involved in ADR reports were: human papillomavirus (HPV) for drug related hospital admissions and entered into a database. vaccine (7.3%), iron preparations (4.5%), vaccines against tick-borne Patients with serious NSAID GID (peptic ulcer, hemorrhage, perforation) encephalitis (2.9%), measles/mumps/rubella (MMR) vaccines (2.4%), were selected and their risk profile was determined. Patients with more diphtheria/tetanus/pertussis/poliomyelitis plus H. Influenzae type b than three risk factors for GID were defined as high risk patients requir- (DTaP-IPV + Hib) vaccines (2.0%), pneumococcal vaccines (1.7%), venla- ing prevention therapies. faxine (1.4%) and atorvastatin (1.4%; 5 of the 12 reports involving hep- Results During the years 2000 to 2007 we identified 214 patients with atotoxicity). The most frequently affected organ systems in ADR serious NSAID GID. 129 (60%) of these patients had a high risk profile. reports according to ICD-10 groups were: diseases of the skin and sub- Only 16% of these patients received a preventive therapy with PPI. We cutaneous tissue (16.9%), diseases of the digestive system (13.6%) -- also found 65 patients with COX-2-inhibitor induced GID, 75% (49) with 18.4% of these relating to liver injury -- and mental and behavioural a high risk and 28% with PPI-medication. disorders (10.4%). Conclusion To decrease the risk for ulceration and more serious com- Conclusion At our centre, we found a leading position of HPV vaccine, plications in NSAID users at a high risk for NSAID GID a PPI medication which might be attributed to a raised awareness concerning recently is proposed. This recommendation wasn’t realised consistently. approved drugs. Vaccines in general were also frequently involved, Acknowledgements Supported by BfArM Project No.: Fo 2.1-68502-201. although the related ADRs were usually mild. Reference 1. Swissmedic. Schweiz A¨ rzteztg 2002; 83: 819--22.

50 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

94 95 HOW TO PRIORITISE MEDICATION HANDLING PREVENTION OF ADMINISTRATION ERRORS ERRORS TO GUIDE QUALITY IMPROVEMENT AND POTENTIAL COST SAVINGS IN D. Niemann1,2, Y. Mayer1,2, K. Ingram1,2, T. Hoppe-Tichy2,3, PAEDIATRIC NEUROLOGICAL PATIENTS 1,2 1,2 W. E. Haefeli and T. Bertsche K. Bergmann1,2, A. Bertsche3, E.-M. Krieg2,4, N. Kunz2, 1 Department of Internal Medicine VI, Clinical Pharmacology and G. Hanke2, T. Hoppe-Tichy2,4, F. Ebinger3, W. E. Haefeli1,2 Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld and T. Bertsche1,2 2 410, 69120 Heidelberg, University of Heidelberg, Cooperation Unit Clinical 1Department of Internal Medicine VI, Clinical Pharmacology and 3 Pharmacy, Im Neuenheimer Feld 410, 69120 Heidelberg, Pharmacy Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld Department, University of Heidelberg, University Hospital, Im Neuenheimer 410, 69120 Heidelberg, 2University of Heidelberg, Cooperation Unit Clinical Feld 670, 69120 Heidelberg, Germany Pharmacy, Im Neuenheimer Feld 410, 69120 Heidelberg, 3Department of Paediatric Neurology, University of Heidelberg, Im Neuenheimer Feld 430, Introduction Drug administration is one of the most error prone pro- 69120 Heidelberg, 4Pharmacy Department, University Hospital, University cesses in pharmacotherapy. These errors are multifaceted. Possible root of Heidelberg, Im Neuenheimer Feld 670, 69120 Heidelberg, Germany causes are knowledge deficits, poor adherence to standards (rule based), or lacking practical skills. Prevention strategies must account Introduction Drug administration in paediatrics is complex and numer- for these causes. Therefore methods to prioritise successful interven- ous factors may contribute to the occurrence of medication errors. tions are needed. Thus, safe drug use requires both, the knowledge concerning particu- Methods and Materials Participants and methods We monitored larities of the dosage form and skills in Good Medication Handling routine drug administration for deviations from predefined handling Practices (GMHP). standards on medical wards of a university hospital. Concurrently, the Methods and Materials A prospective, two period intervention study nurses’ knowledge of drug administration was assessed in a question- was conducted on a neurological ward of a university children’s hospi- naire survey. We then defined urgency and kind of corrective measures tal enrolling all nurses (N = 17) and parents (N = 30) involved in enteral according to a four-field decision matrix that considered potential drug administration. Trained monitors observed routine processes to severity, prevalence, knowledge deficits, and characteristics of the assess the prevalence of critical drug handling errors. Based on this, a drugs involved. GMHP guideline was developed and implemented by a teaching pro- Results In 80% of the monitored processes (n = 1376) at least one gram for nurses and parents. Consecutively, the impact of this inter- deviation from predefined standards was detected. Errors in drug prep- vention on administration error prevalence and containment of direct aration (571 errors in 645 processes) were more frequent than errors in costs was analysed. administration (254/701, P < 0.001) and parenteral drugs (538/492) Results Administration errors were detected in 40.4% (261/646) of pro- were more often involved than oral drugs (252/794, P < 0.001) and cesses conducted by nurses and in 96.6% (28/29) by parents. Overall, drugs administered via gastric tube (35/60, P < 0.001). One third of the the intervention reduced these errors by 80.4% in nurses to 36/453 observed errors were related to high-risk processes and one in nine (P < 0.001) and by 94.2% to 2/36 (P < 0.001) in parents. In all but one errors concerned critical dose drugs. According to the decision matrix, predefined subcategory the number of errors decreased (handling of tube administration for enteral drugs, incompatibilities, poor standards oral liquids, tablet splitting/milling, dissolution/suspension, storage of hygiene, and duration of parenteral drug administration were the after preparation, and administration via gastric tube). Prevention of four errors to be targeted with highest priority. one of the most frequent errors (inappropriate splitting of topiramate Conclusion Drug administration errors are very frequent in internal tablets) resulted in projected cost savings of 532.90€ per patient and medicine. We applied a new decision matrix model to prioritise such year. errors for appropriate prevention strategies. Conclusion Administration errors in children with neurologic disorders are frequent and many of them can only be identified by direct obser- vation. Targeted teaching programs are effective in the prevention of administration errors.

2009 The Authors 51 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

96 TREATMENT OF TYPE 2 DIABETES MELLITUS (T2DM) WITH SITAGLIPTIN-EFFICACY AND SAFETY IN A REAL-LIFE SETTING K. Kusterer1,H.J.Ru¨ßmann2 and C. Hens3 1Praxis Dr. Dr. med Kusterer, Kurfu¨rstenpassage P7, 68161 Mannheim, 2Praxis Dr. Ru¨ßmann, Wilhelminenstr. 22, 46537 Dinslaken, 3MSD SHARP & DOHME´, Medical Affairs, Lindenplatz 1, 85540 Haar, Germany

Introduction To reduce micro- and macrovascular complications in T2DM, a normoglycaemic HbA1c target of <6.5% to 7.0% is internationally recommended. Novel antihyperglycaemic drugs like dipeptidyl- peptidase-4- (DPP-4) inhibitors help to meet this target. An open non- interventional study was performed to evaluate the efficacy and safety profile in a real-life setting. Methods and Materials T2DM patients treated with sitagliptin in combination with metformin or a glitazone because of insufficiently controlled HbA1c were included. Risk factor profile, i.e. HbA1c, fasting blood glucose (FBG), and frequency of hypoglycaemia were examined at the start of sitagliptin therapy and after 12--16 weeks. Results Between 09/2007 and 05/2008, 2211 German sites documented 10 286 evaluable patients (age 62 ± 11 years, 54% males, 84% with cardiovascular or diabetes-related concomitant diseases). Most patients were treated with sitagliptin + metformin (87%). Baseline HbA1c was 8.0 ± 1.2%. It decreased by 0.9 ± 0.95%, with the highest decrease in patients with high baseline values (1.8%, if baseline HbA1c ‡9%). HbA1c decreased by ‡0.5% in 71% of patients; 23.5% (95% CI: 22.7--24.3) reached an HbA1c target £6.5%. FBG decreased by 30 ± 42 mg/dl (baseline: 159 ± 47 mg/dl). No severe hypoglycaemias (95% CI: 0--0.10%/year) and no drug related serious adverse events occurred. The most frequent adverse drug reaction was nausea (21 patients). Conclusion Sitagliptin was well tolerated and achieved similar blood glucose control in a real-life setting comparable to that in randomized controlled trials.

52 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

VARIA

97 98 INFLUENCE OF GENETIC VARIANTS ON INFLUENCE OF DIETARY FAT ON THE THERAPEUTIC OUTCOME IN PATIENTS WITH PERIPHERAL ENDOCANNABINOID-SYSTEM IN DIABETES MELLITUS TYPE 2 LEAN AND OBESE HUMAN SUBJECTS A. Seeringer, S. Parmar, E. Lebedeva, L. Zondler and S. Engeli1, A.-C. Lehmann2,J.Bo¨hnke2, V. Haas1,2, J. Janke2, J. Kirchheiner A. Strauß2,A.Zo¨rner1, D. Tsikas1 and J. Jordan1 Institut fu¨r Naturheilkunde und Klinische Pharmakologie, Helmholtzstr. 20, 1Medizinische Hochschule Hannover, Institut fu¨r Klinische Pharmakologie, 89081 Ulm, Germany Carl-Neuberg-Straße 1, 30625 Hannover, 2Charite´ - Universita¨tsmedizin Berlin, Experimental & Clinical Research Center, Lindenberger Weg 25, Introduction Type 2 diabetes mellitus (T2DM) affects up to 8% of the 13125 Berlin, Germany adult population in western countries. However, treatment with oral antidiabetics is characterized by a considerable amount of therapeutic Introduction Endocannabinoids in blood and adipose tissue are failures and about 64% of T2DM patients do not reach HbA1c level increased in obese subjects whereas FAAH activity is lower. Similar below 7%. Insulin receptor substrate 1 is considered to play a role in changes were induced by a high fat diet in the mouse liver. We the insulin signalling pathway and can influence the response to sulfo- hypothesized that endocannabinoid dysregulation in human obesity nylurea (SU). The Arg972 allele of the IRS1 Gly972Arg polymorphism might be secondary to increased fat ingestion. was associated with an increased risk of nonresponse to sulfonylurea. Methods and Materials Seventeen lean and 12 obese volunteers were Methods and Materials We studied the effects of IRS1 Gly972Arg vari- included. A stabilizing period (30% of caloric intake from fat) was fol- ant on the HbA1c levels in 292 T2DM patients treated with oral antidi- lowed by a randomly assigned period of either 15% or 45% fat intake. abetics. Genotyping was performed using PCR-RFLP methods. Afterwards, subjects entered a second stabilization period and then Results 972Arg heterozygous carriers showed higher HbA1c levels crossed over to a period with 45% or 15% fat intake. Each period compared to wildtype among patients treated with insulinotropic lasted for 2 weeks. At the end of high and low fat periods, we mea- drugs (8.27% versus 7.55%, P: 0.007) whereas no differences were seen sured anandamide in blood before and after a test meal by stable iso- in patients treated with non-insulinotropic drugs (6.39% versus 6.77%; tope dilution GC-MS/MS. We determined ECS gene expression in P: 0.16). In the subgroup of patients with therapeutic failure to SU subcutaneous adipose tissue and skeletal muscle. (n = 66) the carriers of the 972Arg allele had higher mean HbA1c levels Results Fasting anandamide was increased by 23% in obese subjects compared to wildtype (8.7% versus 7.7%; P: 0.007). (P = 0.005), and not influenced by fat intake. After test meal ingestion, Conclusion The 972Arg allele seems to be associated with unfavour- anandamide decreased similarly in lean and obese subjects, indepen- able response to SU in patients with Type 2 diabetes mellitus. There- dently from the fat content of the meal (P = 0.006 at 1h versus base- fore it remains to be studied whether carriers of this variant might line). In obese subjects, adipose tissue DAGL expression was increased benefit from treatment with non-insulinotropic drugs. and MGL and FAAH expression were decreased. ECS genes did not respond to changes in dietary fat. Skeletal muscle ECS gene expression was similar in lean and obese subjects, but high fat intake reduced CB1-R and MGL expression. Conclusion Circulating anandamide and ECS genes in human adipose tissue are not regulated by excessive fat intake. However, dietary fat intake changes ECS gene expression in skeletal muscle.

2009 The Authors 53 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

99 100 CONVECTION-ENHANCED DELIVERY FOR PROBLEMS IN CHOOSING THE RIGHT LOCAL TARGETED THERAPY OF INTRACTABLE EPIDEMIOLOGICAL RESEARCH METHOD EPILEPSY S. Lochner, J. Siegert, C. Schindler, L. Goltz, J. Schro¨der, M. Kosa M. Luz1,2 and M. A. Rogawski3 and W. Kirch 1MedGenesis Therapeutix Inc., 730-730 View Street, Victoria V8W 3Y7, Institut fu¨r Klinische Pharmakologie, Fiedlerstraße 27, 01307 Dresden, Canada, 2MedGenesis Therapeutix Inc., Goeggstr. 17, 68199 Mannheim, Germany Germany, 3Department of Neurology, School of Medicine, University of California Davis, 4860 Y Street, Suite 3700, Sacramento, CA 95817, USA Introduction Epidemiological studies are an important part of medical research for investigating human diseases. Choosing the right method Introduction Focal epilepsy constitutes a significant therapeutic chal- is essential for success and statistical significance of epidemiological trials. In contrast an ill-conceived method can lead to erroneous results lenge, as seizure activity cannot be adequately controlled with drug 1 1 or a lack of validity . treatment in approximately 30% of patients . Convection-enhanced delivery (CED) is a local drug delivery technique that uses bulk flow for Methods and Materials Objectives Although a wide range of medical literature about methods in epidemiological research exists, it often drug distribution and provides an opportunity for local targeted treat- 2 ment of epileptic foci2. poses a barrier in planning such trials . This paper overviews the methods and their advantages as well as their disadvantages. Methods and Materials We examined whether CED infusion of non- diffusible peptides that inhibit the release of excitatory neurotransmit- Results The selection of the right method depends on the intended ters can attenuate kindling measures in fully amygdala-kindled rats. epidemiological topic. Descriptive studies often result in qualitative Rats were implanted with a combination infusion cannula-stimulating information of the population with the help of an average sample. They often provide a basis for generating hypotheses. If clearly defined electrode assembly into the right basolateral amygdala and were treated with x-conotoxins GVIA (0.005, 0.05, and 0.5 nmol) and MVIIA hypotheses of associations or relationships in epidemiology are to be (0.05, 0.15, and 0.5 nmol), and botulinum neurotoxins A and B (1, 3.2, tested, inductive methods with quantitative statistical models should be used. Bias can affect the results adversely. and 10 ng). Results Single 5-ll CED infusions of the test substances near the stim- Conclusion An intensive examination of the epidemiological method, ulation site over 20 minutes led to a dose-dependent increase in the the expected results and the average sample is highly important for afterdischarge threshold, and a dose-dependent decrease in the after- revealing unbiased information or relationships of diseases which are the aim of epidemiological studies. discharge duration and in behavioral seizure score and duration, indicating an inhibitory effect on the triggering and expression of kindled References seizures. The effects lasted for several days (x-conotoxins) or weeks 1. Pocock, S.J., et al., Issues in the reporting of epidemiological studies: (botulinum neurotoxins), while locally administered carbamazepine a survey of recent practice. BMJ, 2004; 329: 883. 2. Sackett, D.L. and J.E. Wennberg, Choosing the best research design (500 nmol) was effective only after 20 min but not at 24 h after the infusion, and vehicle or inactivated toxin had no effect. Seizure protec- for each question. BMJ, 1997; 315: 1636. tion was obtained without detectable neurological or behavioral side effects. Conclusion CED is a potential approach for seizure protection that could represent an alternative to resective surgery in the treatment of focal epilepsies that are resistant to orally administered antiepileptic drugs. References 1. Berg et al. Epilepsia 2003; 44: 1425--1433. 2. Fiandaca et al. Neurotherapeutics 2008; 5: 123--127.

54 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

4. PHARMAKOVIGILANZTAG

1 2 IN VITRO DETECTION AND SEVERE CHOLESTATIC HEPATITIS AFTER FIRST CHARACTERIZATION OF DRUG CYCLE OF TEMOZOLOMIDE HYPERSENSITIVITY USING FLOW CYTOMETRY RADIOCHEMOTHERAPY IN A GLIOBLASTOMA M. Martin1, G. Wurpts2, H. Ott2, J. M. Baron2, S. Erdmann2, PATIENT 2 3 H. F. Merk and B. Sachs H.-D. Orzechowski1, M. Thomae1, W. Kauffmann2, H. Herbst3, 1 Federal Institute for Drugs and Medical Devices, Research, Kurt-Georg- E. Bronder1 and E. Garbe1,4 2 Kiesinger-Allee 3, 53175 Bonn, Department of Dermatology and 1Charite´ - Universita¨tsmedizin Berlin, Klinische Pharmakologie und Allergology, University hospital of the RWTH Aachen, Pauwelsstraße 30, Toxikologie, Luisenstraße 10-11, 10117 Berlin, 2Vivantes Klinikum 3 52074 Aachen, Federal Institute for Drugs and Medical Devices, Prenzlauer Berg, Gastroenterologie, Fro¨belstraße 15, 10405 Berlin, Pharmakovigilance, Kurt-Georg-Kiesinger-Allee 3, 53175 Bonn, Germany 3Vivantes Klinikum Neuko¨lln, Pathologie, Rudower Straße 48, 12351 Berlin, 4Bremer Institut fu¨r Pra¨ventionsforschung und Sozialmedizin, Klinische Introduction Drug hypersensitivity reactions account for only about Epidemiologie, Linzer Str. 10, 28359 Bremen, Germany one-seventh of all adverse drug reaction, but they represent a major problem in drug safety due to their severity and their unpredictability. Introduction Fractionated radiotherapy including administration of the Thus, there is a need to suggest an in vitro method with improved alkylating drug temozolomide (TMZ) represents the current first-line practicability and sensitivity which even carries the opportunity to adjuvant treatment of glioblastoma patients. characterize the pathophysiology of the reaction. Methods and Materials The case (male, 51 years) was detected in the Aim The aim of this study was to assess drug-specific cytokine produc- case-control surveillance study conducted at the German National tion by means of flow cytometry and ELISA as an approach which may Pharmacovigilance Center (PVZ-FAKOS) in Berlin which is funded by be appropriate for routine testing and may provide more information the Federal Institute for Drugs and Medical Devices, Germany (BfArM). about the pathophysiology of the reaction than e.g. proliferation-based Evaluation of drug causality was based on clinical records which includ- assays. ing all diagnostic reports. Methods and Materials Peripheral blood mononuclear cells of 19 Results One day after completion of TMZ treatment (75 mg/m2) the patients were incubated with culprit drugs (n = 28) or irrelevant anti- patient developed nausea and vomiting, followed by generalised jaun- gens (n = 10). Ten healthy persons served as controls for all different dice. Concomitant medication included low-dose dexamethasone and drugs (n = 15). pantoprazole. 4 days after onset of symptoms increased levels of ala- Intracellular interleukin (IL)-5, interferon (IFN)-gamma and IL-10 produc- nine aminotransferase (ALT; 639 U/l) were detected. 5 days later ALT tions were investigated by flow cytometry. In addition, drug-specific was 457 U/l and alkaline phosphatase (AP) level was increased to secretion of IL-5, IL-2 and IFN-gamma were analyzed by ELISA. 261 U/l. The ALT/AP ratio was 1.75. Total bilirubin was markedly Results Drug-specific cytokine production could be demonstrated in increased (12.8 mg/dl) and reached its peak level (25 mg/dl) two 75% of the patients using flow cytometry and in 79% using ELISA. months after TMZ treatment. Histological liver examination confirmed Combining ELISA and flow cytometry increased the sensitivity to 100%. the diagnosis of severe cholestatic hepatitis (SCHEP). Treatment with si- Investigation of typical TH1- and TH2-like cytokines (i.e. IFN-gamma, IL- lymarin and ursodesoxycholic acid failed to show therapeutic efficacy. 5) allowed characterization of the in vitro lymphocyte reactivity pattern. Seven months after onset of symptoms, laboratory examinations still No correlation between in vitro and in vivo phenotype could be found. revealed abnormal values (ALT 286 U/l, AST 75 U/l, AP 545 U/l, bilirubin Conclusion Analysis of drug hypersensitivity by means of flow cytome- 14.3 mg/dl). The ALT/AP ratio was 0.5. Viral infection and autoimmune try proved a useful and reliable approach for the in vitro detection and disorders were excluded by serological testing. Sonographic and MRT characterization of drug hypersensitivities. Combining ELISA with flow examinations did not reveal structural abnormalities of the liver. cytometry further improved sensitivity. Conclusion To our knowledge, this is the first report of SCHEP which is likely caused by TMZ treatment. Tumor patients administered TMZ should be closely monitored for signs of liver injury during treatment.

2009 The Authors 55 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

3 4 PATIENT SELF-MEDICATION AND SERIOUS MHH CENTER OF DRUG SAFETY (ZAS) ADVERSE DRUG REACTIONS (ADRS) D. O. Stichtenoth1, G. Picksak2, H. Alz2, S. Ziesing3, H.-G. Heuft4, 5 1,5 K. Farker1, M. Rottenkolber2, B. Drewelow3, M. Hippius4, W. Beil and J. Jordan 1 W. Siegmund5, P. Thu¨rmann6 and J. Hasford2 for the study Medizinische Hochschule Hannover, Klinische Pharmakologie, Carl- 2 group of the German network of regional pharmakovigilance Neuberg-Str. 1, 30625 Hannover, Medizinische Hochschule Hannover, 3 centres NRPZ Zentralapotheke, Carl-Neuberg-Str. 1, 30625 Hannover, Medizinische 1Pharmakovigilanzzentrum Weimar, Institut fu¨r Pharmakologie und Hochschule Hannover, Medizinische Mikrobiologie, Carl-Neuberg-Str. 1, 4 Toxikologie, Arbeitsbereich Klinische Pharmakologie, Universita¨tsklinikum 30625 Hannover, Medizinische Hochschule Hannover, 5 Jena, Dornburger Straße 159, 07740 Jena, 2Pharmakovigilanzzentrum fu¨r Transfusionsmedizin, Carl-Neuberg-Str. 1, 30625 Hannover, Medizinische Methodenentwicklung und Datenverarbeitung, Institut fu¨r Medizinische Hochschule Hannover, Arzneimittelbeirat, Carl-Neuberg-Str. 1, 30625 Informationsverarbeitung, Biometrie und Epidemiologie (IBE), Ludwig- Hannover, Germany Maximilians-Universita¨tMu¨nchen, Marchioninistr. 15, 81377 Mu¨nchen, 3Pharmakovigilanzzentrum Rostock, Institut fu¨r Klinische Pharmakologie, Introduction Several departments at Medizinische Hochschule Han- Universita¨t Rostock, Schillingallee 70, 18057 Rostock, nover (MHH) have been involved in various aspects of drug therapy 4Pharmakovigilanzzentrum Jena, Institut fu¨r Pharmakologie und with the aim to improve patient safety. Toxikologie, Arbeitsbereich Klinische Pharmakologie, Universita¨tsklinikum Methods and Materials In 2008, we bundled the expertise in a central multi disciplinary unite, the Center of Drug Safety (Zentrum fu¨r Arznei- Jena, Dornburger Straße 159, 07740 Jena, 5Pharmakovigilanzzentrum mittelsicherheit, ZAS). Greifswald, Institut fu¨r Klinische Pharmakologie, Ernst Moritz Arndt Results The Center of Drug Safety provides the joint platform of sev- Universita¨t Greifswald, Friedrich-Loefflerstr. 23d, 17487 Greifswald, eral independent facilities each with a distinct expertise. The central 6Pharmakovigilanzzentrum Wuppertal, Philipp Klee-Institut fu¨r Klinische pharmacy is responsible for dosage forms, compatibility, and batch Pharmakologie, HELIOS Klinikum Wuppertal, Universita¨t Witten/Herdecke, recall among other duties. The Institute of Clinical Pharmacology runs Heusnerstraße 40, 42283 Wuppertal, Germany the Drug Therapy Information Service with a focus on individualized therapy, drug interactions, adverse reactions, drugs in pregnancy and Introduction Self-medication plays an important role in health care, lactation. The Institute for Medical Microbiology helps clinicians to opti- but little is known about the occurrence of adverse drug reactions mize anti-infective therapy. The Institute of Transfusion Medicine con- (ADRs) by self medication. tributes expertise on blood product and related regulatory issues. Methods and Materials The German network of regional pharmaco- Finally, the MHH Drug Committee prepares local guidelines and the vigilance centres (NRPZ) systematically screened nonelective admissions MHH drug list. The Center of Drug Safety is highly visible in the MHH to emergency rooms and departments of internal medicine for drug intranet and provides AID-Klinik (Dosing GmbH, Heidelberg) as drug related hospital admissions in the regions of Greifswald, Jena, Rostock information and interaction database for all MHH departments. Ques- and Weimar. Between 1996 and 2007, 330 patients were admitted due tions from clinical departments are received electronically or by tele- to serious ADRs caused by patients reported self-medication. Medica- phone or fax and answered by best expertise. We informed physicians tions were coded according to the Anatomical Therapeutic Chemical about this service via in-house newsletters and email, as well as in (ATC) classification, ADRs according to MedDRA (Medical Dictionary for workshops and compulsory training for new employees. In response to Regulatory Activities) and SOC (System Organ Classes). the information campaign, searches in AID-Klinik increased from 674 in Results In total, 343 ADRs (causality I2 -- I4 according to Be´gaud) were July 2008 to 3957 in June 2009. The Center of Drug Safety acted con- reported in 166 males and 164 females. Mean age of all patients was sensually to address specific issues at the university hospital, such as 57.3 ± 19.2 years (median 60 years). Most ADRs affected the gastroin- inadequate use of antimycotic drugs and blood products. testinal and immune system. Peptic ulcer haemorrhage, gastrointestinal Conclusion The establishment of the Center of Drug Safety raised the haemorrhage, gastric ulcer, hypersensitivity and erosive gastritis (Med- awareness for problems in drug therapy. To meet this demand, we ini- DRA preferred terms) were the five most frequently reported ADRs tiated a project to implement and evaluate a computerized physician caused by self-medication. The leading drugs responsible for these order entry with clinical decision support system. ADRs were acetylsalicylic acid, diclofenac, and drug combinations with paracetamol or acetylsalicylic acid. Conclusion Analgesics/NSAIDs are often used in self-medication and the use of OTC drugs is not without risks. The frequency figures presented here are most certainly an underestimation as not all self-medications have been identified. Acknowledgements Supported by the Federal Institute for Drugs and Medical Devices, Germany (BfArM Fo¨-Nr. V-11340/68605/2008-2010).

56 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

5 6 PREVENTABILITY OF ADVERSE DRUG ADVERSE DRUG REACTIONS IN A REACTIONS LEADING TO HOSPITAL COMPLEMENTARY MEDICINE HOSPITAL ADMISSION -- ASSESSMENT OF INTER-RATER M. Su¨sskind1,C.Lu¨ke1, E. Jeschke1, S. Pichl1, P. Thu¨rmann2, H. Matthes1 and T. Ostermann3 VARIABILITY WITHIN THE NETWORK OF 1 Forschungsinstitut Havelho¨he (FIH) am Gemeinschaftskrankenhaus REGIONAL PHARMACOVIGILANCE CENTERS Havelho¨he, Kladower Damm 221 Haus 5, 14089 Berlin, 2Philipp Klee- 1,2 1,2 3 4 S. Schmiedl , J. Szymanski , M. Rottenkolber , B. Drewelow , Institut fu¨r klinische Pharmakologie, HELIOS Klinikum Wuppertal, 5 6 7 3 W. Siegmund , M. Hippius , K. Farker , J. Hasford and Universita¨t Witten/Herdecke, Heusnerstr. 40, 42283 Wuppertal, 3Lehrstuhl 1,2 P. A. Thu¨rmann fu¨r Medizintheorie und Komplementa¨rmedizin, Universita¨t Witten/ 1 HELIOS Clinic Wuppertal, Philipp-Klee Institute of Clinical Pharmacology, Herdecke, Gerhard-Kienle-Weg 4, 58313 Herdecke, Germany Heusnerstrasse 40, D-42283 Wuppertal, 2University Witten/Herdecke, Chair 3 of Clinical Pharmacology, Witten, Ludwig-Maximilians-University Introduction Complementary Alternative Medicine (CAM) is widely Muenchen, Institute of Medical Informatics, Biometry and Epidemiology, used; Anthroposophic medications (AMED) are prescribed by physicians 4 Munich, University of Rostock, Regional Pharmacovigilance Center in 60 countries. However, systematically collected safety data on use of Rostock, Institute of Clinical Pharmacology, Rostock, 5University of AMED are sparse. Our aim was to assess and describe adverse drug Greifswald, Regional Pharmacovigilance Center Greifswald, Institute of reactions (ADRs) caused by CAM and in particular by AMED in an An- Clinical Pharmacology, Greifswald, 6Regional Pharmacovigilance Center throposophic community hospital. Jena, Department of Clinical Pharmacology, Institute of Pharmacology Methods and Materials The prospective study was conducted at the and Toxicology, University of Jena, Jena, 7Regional Pharmacovigilance Gemeinschaftskrankenhaus Havelho¨he (GKH) in Berlin, where about Center Weimar, Department of Clinical Pharmacology, Institute of 63% of our in-patients receive one or more CAM-Med (median 3 [IQR: Pharmacology and Toxicology, University of Jena, Weimar, Germany 1; 5]), 58% receive at least one AMED (median 3 [IQR: 1; 5]). Over a study period of six months, patients admitted to six medical wards Introduction Determing the fraction of preventable ADRs exactly is were assessed for ADRs by a trained physician applying intensified sur- hampered by inter-rater variability (IRV) to a significant extent. Within veillance. Suspected adverse drug reactions (ADRs) were defined the German Network of Regional Pharmacovigilance Centers (NRPC), according to internationally accepted criteria and classified in terms of ADRs leading to hospitalisation are collected in four regional centers causality and avoidability following validated algorithms. Community- (RC) and quality assurance (QA) is performed independently1.We acquired ADRs (n = 97, 31.5% of ADRs) were excluded from results pre- aimed to quantify IRV of 8 different items concerning ADR preventabil- sented here. ity (e.g. drug-drug interaction, dose adjustments) which were assessed Results Out of 3813 patients admitted, 174 patients (4.6%) experi- by both, RC and QA. enced 211 ADRs (CTCAE 2/3 n = 191, 90.5%, CTCAE 4/5 n = 20, 9.5%) Methods and Materials Out of all cases documented in 2008 and during their hospital stay. Median age of patients experiencing ADRs 2009, 100 ADRs were randomly chosen. IRV were analysed for ADRs was 72.0 (IQR: 61.0; 80.0), 62.1% were females. 57 ADRs (27.0%) were assessed as ‘probable’ or ‘definite’ by the QA (e.g. absence of relevant serious, 35 (16.6%) were classified as avoidable. Six ADRs (2.8% of admission related co-morbidity). Since there are three potential ADRs) were caused by eight suspected AMED (all CTCAE grade 2). answers (‘yes’, ‘no’, ‘not known’) for assessing each item, a 3 · 3-square Conclusion The presented data of ADRs assessed in a hospital with fre- table was used for evaluating concordance between RC’s and QA’s pre- quent prescriptions of AMED confirm the ambulatory experience that ventability assessments. ADRs caused by AMED are usually mild and occur only occasionally. Results Out of 100 ADRs, 80 cases were assessed as ‘probable’ or ‘definite’ ADRs and included in the final analysis. Best agreement (95.0%) was observed for the item non-consideration of contraindications and precautions regarding over the counter drugs whereas lowest agreement (68.8%) was found for required dose adjustments related to age, gender and co-morbidities. In 36 cases (45%), all preventability statements were assessed in complete concordance by either RC and QA. Conclusion For a sample of ADRs leading to hospitalisation we found a good agreement in assessing preventability within the NRPC. We will further analyse non-agreement focussing on specific ADR characteristics and an algorithm for assessing overall preventability will be developed. Acknowledgements Supported by BfArM Project No.: Fo 2.1-68502-201. Reference 1. Schneeweiss et al. Admissions caused by adverse drug events to internal medicine and emergency departments in hospitals: a longitudinal population-based study. Eur J Clin Pharmacol 2002; 58: 285-- 291.

2009 The Authors 57 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

7 8 MEASURES TO IMPROVE SAFETY IN DRUG FATAL MULTIPLE ORGAN FAILURE IN THERAPY -- THE FEDERAL MINISTRY OF ASSOCIATION WITH A SINGLE HEALTH ACTION PLAN FOR IMPROVEMENT INTRAMUSCULAR INJECTION OF PIROXICAM OF MEDICATION SAFETY (2008/2009) AND DEXAMETHASONE AND ORAL INTAKE A.-F. Aly and H. Mo¨ller OF DICLOFENAC ¨ AkdA, Herbert-Lewin-Platz 1, 10623 Berlin, Germany T. Stammschulte1, R. Arnold2, K. Brune3 and U. Gundert-Remy1 1Arzneimittelkommission der deutschen A¨rzteschaft, Herbert-Lewin-Platz 1, Introduction Since the mid-1990s risks and errors associated with drug 2 1 10623 Berlin, Universita¨tsklinikum Jena, Institut fu¨r Rechtsmedizin, therapy got into focus of patients, physicians and other health profes- Fu¨rstengraben 23, 07740 Jena, 3Friedrich-Alexander-Universita¨t Erlangen- sionals. Besides individual consequences for affected patients, Adverse Nu¨rnberg, Institut fu¨r Exp. und Klinische Pharmakologie und Toxikologie, Drug Events lead to significant economic burden on the health care Fahrstraße 17, 91054 Erlangen, Germany system. Since experts as the advisory council on the assessment of developments in the Health Care System in its reports 2003 and 20072 The Drug Commission of the German Medical Association (DCGMA) is consistently claimed increased attention to safe medication practice in notified about 2500 suspected adverse drug reactions annually which Germany the plan of action for improvement of medication safety are assessed by MDs at the DCGMA office. A case reported hinting at a 2008/2009 was developed. serious, acute allergic reaction is presented here. A 27-year-old man Methods and Materials The action plan involves all participants in presented to an emergency unit with back pain lasting for 2 days. A order to detect safety problems, to work out precise strategies for the lumbar spine syndrome was diagnosed. After i.m. injection of 20 mg improvement of the medication process and to identify topics for sci- piroxicam with dexamethasone (dose not stated) the patient reported entific research. To supervise the activities a steering group supported perioral numbness lasting a few minutes. He was discharged with a by a scientific secretariat started working in October 2008 and is prescription of 75 mg diclofenac twice daily. Ten minutes after taking located at the Drug Commission of the German Medical Association. the first dose muscular cramps occurred, the patient became somno- Results Some of the problems addressed in the action plan require lent. At re-admission to the hospital the findings were: RR 127/80, long-term structural improvements as e.g. computerized decision sup- heart rate 111/min. The skin showed multiple bruises. Laboratory: port systems. Other issues have been already completed e.g. an inter- hemoglobin 7.9 g/dl, thrombocytopenia (62 000/ll), leucocytosis active website containing comprehensive information on drug safety (17 300/ll), CRP tenfold upper normal range, serum myoglobine 357 l/ pregnancy and lactation and a leaflet advising patients about safe l (<90), serum creatinine 1.8 g/dl, bilirubin 1.87 mg/dl, thromboplastin medication practice. For evaluation of actions patient safety indicators time 67%, procalcitonin 0.56 lg/l, ferritin 15 137 lg/l. A CT scan for drug safety were selected by an expert group after a systematic showed liver enlargement, ascites, pleural and pericardial effusions. In review of literature. spite of intensive care, the patient died from multiple organ failure the Conclusion To improve medication practice in the future and to next morning. A post mortem confirmed shock as cause. No evidence address newly detected problems an updated sequel to the plan of of infectious diseases, use of illicit drugs or life-threatening diseases action will be introduced in March 2010. was found. After having ruled out alternative explanations, the con- References comitant administration of dexamethasone, piroxicame and diclofenac 1. L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, eds., To Err Is Human: was judged the most probable cause for the fatal organ failure. Building a Safer Health System (Washington: National Academies Despite extensive diagnostic measures and a post mortem, the causal- Press, 1999).The Institute of Medicine report on medical error: over- ity assessment remains ‘possible’ or ‘probable’. view and implications for pharmacy. Kohn LT. Am J Health Syst Pharm 2001 Jan 1; 58(1): 63--6. 2. Sachversta¨ndigenrat zur Begutachtung der Entwicklung im Gesund- heitswesen, Gutachten 2007, Kooperation und Verantwortung. Voraussetzungen einer zielorientierten Gesundheitsversorgung.

58 2009 The Authors Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59 Poster Presentations

9 FATAL ADVERSE DRUG REACTIONS: A SYSTEMATIC REVIEW A. Johnsson, S. Walter, D. Grandt, W. Niebling and U. Gundert-Remy Drug Commission of the German Medical Association, Herbert-Lewin-Platz 1, 10623 Berlin, Germany

Introduction Adverse drug reactions (ADRs) caused the death of 0.32% of hospitalized patients in a USA meta-analysis (1998) translating to approximately 106 000. In Germany, estimates were published on the number of deaths caused by ADR as 8000 to 16 000, when medication errors were included up to 57 000. This study provides an over- view on ‘mortality due to drug therapy’ analyzing recent literature (1998--2008). Methods and Materials A systematic review of the literature was performed according to the Handbook for Systematic Review of Interven- tions of the Cochrane Collaboration with use of databases (Medline, EMBASE, and ISI Web Knowledge). Data on the percentage of deaths by ADRs were extracted. The influence of several factors (study-type, health system) was evaluated. Results From 3093 hits 45 studies were analyzed containing data from hospitals, ambulatory care centers, nursing homes, death certificates and spontaneous ADR-reporting systems. The incidence of medication related death is 0.003%--0.47% in in-patients, depending on study design. In death certificate studies fatal ADR was reported to be 0.01%, 0.42% and 3.1% per study population. Spontaneous ADR-reporting systems gave fatal ADR between 0.03 and 5.09 per 100 000 inhabitants compared to 1.47 per 100 000 in Germany. Conclusion Based on the performed analysis the number of drug- related deaths can only be estimated with a high degree of uncertainty. We estimated approximately 24 000 drug-related deaths per year in Germany based on examination of the German spontaneous ADR-reporting system and confirmed by data from death certificates.

2009 The Authors 59 Journal Compilation 2009 The British Pharmacological Society, Br J Clin Pharmacol, 68 (Suppl. 1), 6--59