Predicting Response and Exposure Changes in Cirrhosis for Effectiveness

Objective: to identify and quantify the effect of changes in liver-metabolism that occur in different grades of cirrhosis disease severity on the PK of five probe drugs that are each selectively metabolised by one CYP isoform using a probe drug cocktail as proxy.

Study design: Single-dose interventional PK study

Study population: 45 patients with (decompensated) cirrhosis, 18 years or older.

Intervention: This study consists of a single intervention where patients receive a single oral administration of a drug probe cocktail. The oral probe drug cocktail consists of 100 mg caffeine, 5 mg warfarin, 20 mg esomeprazole, 50 mg metoprolol and 0.03 mg/kg midazolam.

Main study parameters/endpoints: The primary endpoint is the unbound clearance (CL) of each parent of the probe drugs with the total and unbound area under the plasma concentration versus time curve (AUC) of each drug. Secondary endpoints include PK parameters such as volume of distribution of the central (V1) and peripheral compartment (V2) and intercompartment clearance (Q) of each probe drug.

Secondary study parameters are:

• To identify covariates that may influence PK changes in cirrhosis in the development of a population PK model:

• Effect of different disease severity scores on PK (MELD, MELD-Na, MELD 3.0, reMELD-Na).
• Effect of presence of portal hypertension (ascites, HE, SBP, variceal bleeding)
• Effect of severity of portal hypertension on PK (spleen stiffness measurement; SSM)
• Effect of inflammation on PK
• Effect of ACLF on PK
• Effect of concurrent AKI on PK
• Effect of plasma albumin and bilirubin on PK
• Effect of CYP-polymorphisms on PK (metaboliser status and/or activity score of each CYP enzyme)

Inclusion criteria

• Age ≥ 18 years
• Clinical, radiological and/or histological diagnosis of cirrhosis
• Informed consent signed prior to participation in the study

Exclusion criteria

• Original MELD score > 30
• Estimated creatinine clearance < 30 mL/min, calculated by using the Cockcroft-Gault equation
• Known poor metaboliser status for one of the CYP enzymes (CYP1A2, CYP2C9, CYP2C19, CYP2D6, and CYP3A) described in the medical record
• Previous clinically relevant adverse reaction or intolerance to one of the drugs in the probe drug cocktail
• Recent exposure to one of the drugs in the drug probe cocktail within five elimination half-lives prior to drug administration (corresponding to approximately 1-10 days depending on the probe drug)36-40:

• caffeine: 5h x 5 = 25 hours
• warfarin: 50h x 5 = 250 hours
• esomeprazole: 1.3h x 5 = 6.5 hours
• metoprolol: 3.5h x 5 = 17.5 hours
• midazolam: 2.5h x 5 = 12.5 hours
• Absolute contraindication for one of the drugs in the probe drug cocktail36-40:

• caffeine: drug hypersensitivity
• warfarin: drug hypersensitivity and active bleeding
• esomeprazole: drug hypersensitivity, congenital long QT syndrome and suspected gastrointestinal malignancy
• metoprolol: drug hypersensitivity, cardiogenic shock, second- and third degree AV block, bradycardia (< 50 beats per minute), sick sinus syndrome including SA block, symptomatic hypotension (mean arterial pressure < 65 mmHg), metabolic acidosis and untreated pheochromocytoma
• midazolam: drug hypersensitivity, severe chronic obstructive pulmonary disease, myasthenia gravis, sleep apnoea syndrome requiring CPAP, Parkinson's disease, severe respiratory insufficiency or acute respiratory depression
• Interactions with strong to moderate CYP inhibitors and inducers of the following P450 enzymes: CYP1A2 (inhibitors: ciprofloxacin, fluvoxamine), CYP2C9, CYP2C19, CYP2D6 (inhibitors: bupropion, cinacalcet, fluoxetine, quinidine, paroxetine, terbinafine) and CYP3A (inducers: apalutamide, carbamazepine, efavirenz, enzalutamide, phenobarbital, phenytoin, hypericum, lumacaftor, mitotane, nevirapine, primidone, rifabutin, rifampicin; inhibitors: clarithromycin, cobicistat, erythromycin, itraconazole, ketoconazole, posaconazole, ritonavir, voriconazole)41,42
• Use of concomitant medication with a clinically relevant PK or PD interaction with one or more components of the probe drug cocktail, if the interaction is expected to affect PK endpoint interpretation or compromise participant safety and cannot be appropriately managed
• Refusing or unable to give informed consent (e.g. hepatic encephalopathy)