Study on Chronic Kidney Disease's Impact on Warfarin Disposition

A Pilot Study of the Effect of Chronic Kidney Disease on Steady-State Disposition of Warfarin and Warfarin Alcohols Osama Alshogran, MS, PhD Assistant Professor of Clinical Pharmacy Faculty of Pharmacy Jordan University of Science and Technology 1

Outline Introduction: CKD, PK, elderly Previous data: preclinical work Hypothesis & aims Major conclusions Acknowledgments 2

Chronic Kidney Disease (CKD) Epidemiology Affects ~26 million Americans Prevalence: 13% in all US population Incidence: ESRD: 400 cases/million in the US Mortality: 15-20% of ESRD patients die annually Cost: $57.5 billion: annual Medicare costs for CKD - 28% of Medicare spending http://www.usrds.org/atlas.aspx 3 Levey, A. S. and Coresh, J. Lancet, 379:165-80 (2012). Weiner, D. E. Clin Pharmacol Ther, 86:566-9 (2009).

CKD in Elderly In participants 70 years old and older in the 1999 2004 National Health and Nutrition Evaluation Survey (NHANES), the prevalence of CKD is 46.8% compared to 6.71% in those between 40 59 years of age Coresh J. Am. J. Kidney Dis. 41, 1-12, 2003 Leavy AS., et al. Am J Kidney Dis. 2009;53(3 Suppl 3):S4-16. 4

PK in Elderly Absorption: decrease in small-bowel surface area, slowed gastric emptying, and an increase in gastric pH Distribution: body fat generally increases and total body water decreases. Serum albumin decreases and 1-acid glycoprotein increases Metabolism: Elimination through cytochrome P-450 enzyme system decreases with age Excretion: with aging there is a decrease in renal elimination 5

Kidney Disease Affects Drug Disposition Absorption Distribution Metabolism Excretion 6 Velenosi, T. J. and Urquhart, B. L. Expert Opin Drug Metab Toxicol, 10:1131-43 (2014).

Kidney Disease Affects Non-Renal Clearance 7

Non-Renal Drug Clearance Major Pathways Oxidation (CYP450) Reduction Hydrolysis Phase I Glucuronidation Acetylation Sulfation Phase II Uptake Transporters Efflux Transporters Phase III 8 D ring B and Petzinger E. Drug Metab Rev. 2014 Aug;46(3):261-82 Rowland A et al. Int J Biochem Cell Biol 45:1121-1132, 2013.

Phase I Reductases Quinone Reductases Short-chain Dehydrogenase Reductase (SDR) Reductase Enzymes Carbonyl Reducing Enzymes Aldo-Keto Reductase (AKR) 9 Barski OA, et al. Drug Metab Rev. 2008. 40:553-624. Malatkova, P. and Wsol, V. Drug Metab Rev, 46:96-123 (2014).

Warfarin is a Highly Metabolized Drug CYPs OH-WAR Phase II conj. Warfarin Reductases 30% 50% WAR-Alcohols Urine Urine 15-20% Urine R/S 10 Jones DR et al. Drug Metab Rev, 2010. 42(1): p. 55-61. Lewis RJ et al. J Clin Invest. 1974 Jun;53(6):1607-17. Banfield C et al. Br J Clin Pharmacol. 1983 Dec;16(6):669-75.

Warfarin Reduction Warfarin Warfarin Alcohols * R/S R/S Reductases RS, SR Alcohol 1 RR, SS Alcohol 2 11 Chan KK et al. J Med Chem. 1972 Dec;15(12):1265-70. Alshogran OY et al. J Chromatogr B. 2014 Jan 1;944:63-8.

Warfarin Use in Kidney Disease is Challenging Bleeding: 2-5 fold increased risk of bleeding Stroke: Warfarin use double the risk of stroke (HR: 1.93) 89% increase in hospitalization from stroke Mortality: 27% increased risk of mortality Dosing: Moderate: 10% lower maintenance dose Severe: 20% lower maintenance dose Limdi, N.A., et al. J Am Soc Nephrol. 2009; 20(4): 912-921 Chan, K.E., et al. J Am Soc Nephrol. 2009; 20(4): 872-8112 Limdi, N.A., et al. Am J Kidney Dis. 2010; 56(5): 823-31 Chan, K.E., et al. J Am Soc Nephrol, 2009. 20(10): 2223-33

Hypothesis & Aims Warfarin Warfarin Alcohols * R/S R/S Reductases CKD Major Objective: pharmacokinetics in kidney disease patients To assess steady-state warfarin 13

Warfarin Reduction is Selectively Decreased in Cytosol 39% 14 Alshogran OY. Drug Metab Dispos. 2015 Jan;43(1):100-6.

Warfarin Reduction is Decreased in Microsomes 87% 43% 15 Alshogran OY. Drug Metab Dispos. 2015 Jan;43(1):100-6.

Decreased Protein Expression of Rat Hepatic Reductases in CKD 16 Alshogran OY. Drug Metab Dispos. 2015 Jan;43(1):100-6.

Patients Demographics & Clinical Data Control (n=11) 70.9 9.7 ESRD (n=10) 74.8 5.3 P Characteristic Age (yr; mean SD) NS BMI (kg/m2; mean SD) Missing (n) 22.7 4.8 1 25.8 7.3 0 NS Gender [n (%)] Male Female Missing 7 (63.6) 3 (27.3) 1 (9.1) 7 (70%) 3 (30%) 0 (0) NS Race [n (%)] Caucasian African 11 (100) 0 (0) 8 (80) 2 (20) NS No. of Comorbid Conditions [n (%)] 0 or 1 2 - 4 5 5 (45.5) 6 (54.5) 0 (0) 0 (0) 7 (70) 3 (30) 0.016 Comorbid conditions were hypertension (10 patients), congestive heart failure (8), diabetes (6), chronic obstructive pulmonary disease (5), and coronary artery disease (4) 17

Activity in Human Cytosol & Microsomes 27% 22% Alshogran OY. Drug Metab Lett. 2015;9(2):111-8 18

Protein Expression of Human Hepatic Reductases 19 Alshogran OY. Drug Metab Dispos. 2015 Jan;43(1):100-6.

Aim: To assess steady-state warfarin pharmacokinetics in kidney disease patients: a pilot study Patient population (n=25) Moderate CKD (n=4) eGFR 30-60 mL/min/1.73m2 Severe CKD (n=5) eGFR 15-30 mL/min/1.73m2 ESRD (n=5) eGFR <15 mL/min/1.73m2 ESRD/HD (n=5) eGFR <15 mL/min/1.73m2 Normal/mild CKD (n=6) eGFR> 60 mL/min/1.73m2 20 Levey AS. et al. Ann Intern Med. 2009;150:604-612.

Patients Demographics & Clinical Characteristics All patients (n=25) Normal/Mild (n=6) Moderate (n=4) Severe (n=5) ESRD (n=5) ESRD/HD (n=5) P eGFR 31.4 26.6 72 6.8 42.8 5.2 19 3.4 12.6 2.8 4.6 2.0 <0.001 (mL/min/1.73m2) Age (year) 73.4 11 65 10.9 70.5 12.6 79.4 4.7 80.4 9.9 72.6 10.6 0.105 BMI (kg/m2) 29.8 4.9 29 2.4 30.0 3.4 30.5 4.3 29.5 5.3 30.4 8.8 0.989 Gender (% male) 52 50 50 60 80 20 0.439 Race (% white) 96 100 100 100 100 80 0.384 Serum albumin (g/dL) 3.9 0.35 4.2 0.32 4.1 0.25 3.9 0.22 4.0 0.29 3.7 0.48 0.171 Warfarin dose (mg/week) 28.6 14.3 39.5 15.4 25.6 8.3 28.6 14 20.3 8.7 28.4 19 0.270 Blood sampling time (h) 15.9 3.3 16.2 3.1 16.1 1.0 15.4 3.1 16.4 5.3 15.2 3.6 0.978 21

Patients Demographics & Clinical Characteristics All patients (n=25) Normal/Mild (n=6) Moderate (n=4) Severe (n=5) ESRD (n=5) ESRD/HD (n=5) P CYP2C9 genotypes wild type (n, %) at least one mutant allele (n, %) 16 (64) 5 (31) 2 (12.5) 4 (25) 3 (19) 2 (12.5) 0.532 9 (36) 1 (11.1) 2 (24.4) 1 (11.1) 2 (24.4) 3 (33.3) VKORC1 genotypes extensive activity (n, %) intermediate/poor activity (n, %) high activity (n, %) 12 (48) 4 (33.3) 1 (8.3) 2 (16.7) 3 (25) 2 (16.7) 0.779 8 (32) 5 (20) 1 (12.5) 1 (20) 1 (12.5) 2 (40) 2 (25) 1 (20) 2 (25) 0 (0) 2 (25) 1 (20) 22

Clinical Study Approach Study protocol was approved by the Research and Ethics Committee of Maisonneuve-Rosemont Hospital. All subjects provided written informed consents. Single blood sample was collected from patients who are under long-term warfarin therapy. Analytes were measured using LC-MS/MS. Total/ free warfarin and alcohols Total/ free warfarin enantiomers (R & S) Steady-state PK analyses: CLtotal = D/(Css ) CLu = CLtotal/fu fu= Cf/Ct Alcohols exposure S/R warfarin ratio 23 Jensen BP. et al. Br J Clin Pharmacol 2012. 74:797-805

Warfarin Clearance & Kidney Disease No differences were found in warfarin clearance among CKD patients 24

Predictors of Warfarin Clearance 25

GFR Correlation with Warfarin Dose 26

Age Correlation with Warfarin Dose Regression: age was the only significant modifier of average weekly warfarin dose 27

Warfarin Alcohols Concentration & Kidney Disease Increased alcohol 2 dose- normalized concentrations in ESRD * p<0.05 28

S/R Warfarin Ratio & Kidney Disease Increased S/R ratio in ESRD * p<0.05 29

Conclusions As age increases, a significant decline in warfarin dose and clearance is observed. 6-fold increase in the exposure of warfarin alcohol 2 in ESRD (HD) compared to control/mild CKD patients. 2.5-fold increase in warfarin S/R ratio in ESRD/HD versus control/mild or severe CKD patients. 30

Acknowledgments University of Pittsburgh Thomas Nolin, PharmD, PhD University of Montreal Vincent Pichette, MD, PhD Francois Leblond, PhD Jordan University of Science & Technology (JUST) 31

Phase I Reductases Quinone Reductases NADPH Quinone Oxidoreductase (NQO)_Cytosol Short-chain Dehydrogenase Reductase (SDR) Reductase Enzymes Carbonyl Reductase (CBRs)_Cytosol Carbonyl Reducing Enzymes 11 -Hydroxysteroid Dehydrogenase (11 -HSD)_Microsomes Aldo-Keto Reductase (AKR) Aldehyde Reductase (AKR1A) and Aldose Reductase (AKR1B)_Cytosol 3 -Hydroxysteroid Dehydrogenase (AKR1C)_Cytosol 32 Barski OA, et al. Drug Metab Rev. 2008. 40:553-624. Malatkova, P. and Wsol, V. Drug Metab Rev, 46:96-123 (2014).

Reductases & Drug Substrates Quinone Reductases Carbonyl Reducing Enzymes Short-chain Dehydrogenase Reductase (SDR) Aldo-Keto Reductase (AKR) Ketoprofen Ketotifen Loxoprofen Tibolone Befunolol Dolasetron Oracin Naltrexone Ketoprofen Nabumetone Naloxone Naltrexone Metyrapone Mitomycin C Daunorubicin Doxorubicin Oracin Benfluron Daunorubicin Doxorubicin Bupropion Eperisone Prednisone Acetoheximide Daunorubicin Doxorubicin 11 - HSD1 AKR 1A1 AKR 1C1 AKR 1C2 AKR 1C4 CBR1 CBR3 NQO1 Cytosol Microsomes Cytosol Quercetin, Menadione, Ethacrynic acid, Rutin Indomethacin 18 - glycyrrhetinic acid Flufenamic acid, Indomethacin, Phenolphthalein Barbital Dicoumarol 33 Matsunaga T, et al. Drug metabolism and pharmacokinetics. 2006. 21:1-18. Malatkova P and Wsol V. Drug Metab Rev. 2013

Does CKD Affect Drug Reduction? 34 Turpeinen, M et al. Br J Clin Pharmacol, 64: 165-73 (2007) Yoshida, H. et al. Cancer Chemother Pharmacol, 33: 450-4 (1994).

Reductase Drug Substrates by Class Drug Class Drug Class L-691,121* Ketotifen* Benfluron* Daunorubicin Dimefluron Doxorubicin Epirubicin Idarubicin* Iododoxorubicin Mitomycin C Oracin* Wortmannin* Warfarin Antiarrhythmic Antiasthmatic Anticancer Anticancer Anticancer Anticancer Anticancer Anticancer Anticancer Anticancer Anticancer Anticancer Anticoagulant Haloperidol* Timiperone* Boceprevir* S-1360 Levobunolol Metyrapone Ethacrynic Acid Pentoxifylline Oxisuran Eperisone HY-770 Tolperisone CS-670 Flobufen* Ketoprofen Loxoprofen Nabumetone* Methylnaltrexone Naloxone Naltrexone* Glucocorticoids Norethynodrel* Tibolone* Naftazone Menadione Antipsychotic Antipsychotic Antiviral Antiviral -Blocker Diagnostic Diuretic Hemorheological Immunosuppressive Muscle relaxant Muscle relaxant Muscle relaxant NSAID NSAID NSAID NSAID NSAID Opiate antagonist Opiate antagonist Opiate antagonist Steroid Steroid Steroid Vasoprotectant Vitamin (K3) Nafimidone Bupropion E/Z-10-oxonortriptyline Acetohexamide* Dolasetron* Oxcarbazepine* Fenofibrate Triadimefon Befunolol* Ketanserin* TA-510 Bromperidol* Anticonvulsant Antideprassant Antideprassant Antidiabetic Antiemetic Antiepileptic Antihyperlipidemia Antifungal Antihypertensive Antihypertensive Anti-inflammatoy Antipsychotic 35

Pharmacological Activity/ in-vivo Alcohols possess anticoagulant activity - Decrease activity level of clotting factors (Vit K dependent) - Alcohol 1 = Alcohol 2 in the activity - RS: sustained decrease in coagulation activity - The activity is lower than that of warfarin 36 Lewis RJ et al. Ann N Y Acad Sci. 1971 Jul 6;179:205-12. Chan KK et al. J Med Chem. 1972 Dec;15(12):1265-70.

Kinetics Excreted unchanged in urine: 15-20% of warfarin dose At dose of 0.75mg/kg: peak: R-warfarin (ng/mL) S-warfarin (ng/mL) RS 860 380 25 7-OH SS SR 1000 130 37 7-OH RR The clearance rate of RS alcohol is comparable to that of warfarin; nevertheless the clearance rate of the other alcohols (RR, SR, and SS) is 2.5-3 folds faster. Half-life: RS: 34 hrs SR, SS, RR: 13 hrs Lewis RJ et al. J Clin Invest. 1974 Jun;53(6):1607-17. Banfield C et al. Br J Clin Pharmacol. 1983 Dec;16(6):669-75. Lewis RJ et al. Ann N Y Acad Sci. 1971 Jul 6;179:205-12. 37 Chan KK et al. J Med Chem. 1972 Dec;15(12):1265-70.

Activity in-vitro Activity was tested based on the inhibition of rat microsomal VKOR enzyme 38 Gebauer M. Bioorg Med Chem. 2007 Mar 15;15(6):2414-20.

Protein binding Warfarin: 99% Alcohols: 98% OH-Met: 96% 39 Chan E et al. Chirality. 5610-615 (1993)

Reductases By Drug Substrates 1B10 2.6 3.8 7.7 11.5 1A1 1C1 3.8 1C2 17.9 7.7 1C3 1C4 CBR1 16.7 CBR3 11B-HSD1 20.5 7.7 NQO1 40

Multiple Regression Analysis P 0.01 0.025 <0.001 Outcome Total Warfarin CL (mL/min) Predictor Age Serum albumin Constant Beta -0.049 -0.124 10.613 SE 0.017 0.051 2.351 Total R-warfarin CL (mL/min) Age -0.044 0.018 0.024 Serum albumin Constant -0.154 10.981 0.054 2.449 0.009 <0.001 Total S-warfarin CL (mL/min) eGFR Constant 0.025 8.953 0.012 3.341 0.045 <0.001 Free Warfarin CL (mL/min) Age Constant -5.548 468.80 2.116 168.68 0.016 0.011 Free R-warfarin CL (mL/min) Age Constant -5.257 589.47 1.999 149.63 0.015 0.001 Free S-warfarin CL (mL/min) None 41

Alcohols vs GFR 42

S/R vs. GFR 43

Protein binding 44