Ethical Approval
This article does not contain any studies with human participants or
animals performed by any of the authors.
Abstract
Background
and Purpose: Rivaroxaban as an oral anticoagulant is widely used for
the prevention and treatment of thromboembolic disease. Previous studies
revealed cytochrome P450 (CYP)–mediated metabolism of rivaroxaban
mainly involves CYP2J2 and CYP3A4. Imatinib, sunitinib and gefitinib are
three tyrosine kinase inhibitors (TKIs) that are extensively applied for
anti-cancer therapy. Statistical research has shown cancer patients are
at approximately 4-7–fold higher risk of vein thromboembolism than
normal patients. Therefore, rivaroxaban and TKIs have a profound
combination foundation. This study aimed to comprehensively assess the
combination safety of rivaroxaban with TKIs in vitro.
Experimental Approach: First, the inhibitory activity of the
three TKIs was screened. Second, to comprehensively evaluate their
inhibitory potential, the reversible and mechanism-dependent inhibitory
kinetic constants of three TKIs on CYP2J2 and CYP3A4 were determined.
Docking simulation was used to explore the molecular mechanism. Finally,
drug-drug interaction (DDI) risks of the combination were assessed using
pharmacokinetic data of cancer patients.
Key Results: Imatinib and gefitinib exerted significant
reversible inhibition of both CYP2J2 and CYP3A4, while sunitinib only
showed reversible inhibition of CYP3A4, not CYP2J2. Three TKIs also
showed time-dependent inactivation of CYP3A4 and slightly on CYP2J2.
Notably, sunitinib had a significantly stronger inactivation effect on
CYP3A4 than the other TKIs, with a 4.14-fold IC50 shift.
Imatinib was predicted to cause a 114–244% increase in rivaroxaban
exposure.
Conclusion and Implication: Imatinib showed the strongest
inhibition, which was predicted to have a moderate DDI risk. These
results provide evidence for medication guidance when combining
rivaroxaban with TKIs.
Keywords: rivaroxaban, tyrosine kinase inhibitors, combined
medication, CYP2J2, CYP3A4, drug-drug interaction, medication safe
Introduction
Rivaroxaban, an oral anticoagulant, is widely used for the prevention
and treatment of thromboembolic disorders in clinical practice. It
exhibits direct anticoagulant effects by inhibiting coagulation factor
Xa. Although in vivo pharmacokinetic data are stable, bleeding is still
a risk factor that be considered for medication safety. Our previous
studies have shown CYP2J2 and CYP3A4 to be the major isoforms involved
in the metabolic process of rivaroxaban, and importantly CYP2J2 showed
~39-fold higher catalytic efficiency than CYP3A4 (Zhao
et al., 2021). Notably, CYP2J2, which dominated the metabolism of
rivaroxaban, is always not considered in routine drug-drug interaction
(DDI) research due to its lower abundance in the liver. It is this lack
of research that may lead to the possibility of severe
rivaroxaban-related clinical DDIs being overlooked.
Cancer-related vein thromboembolism (VTE) is closely associated with
increased morbidity and mortality (Song, Rosovsky, Connors &
Al-Samkari, 2019). In cancer patients, the presence of tumours is one of
the risk factors for VTE. Additionally, both the hypercoagulability of
cancer patients and the thrombogenicity of anti-cancer agents are
reasons for the high incidence of VTE in cancer patients (Shalhoub et
al., 2017; Zamorano et al., 2016). According to statistics, cancer
patients have an approximately 4–7-fold higher risk of VTE than normal
patients, and cancer patients with VTE account for about 20% of all VTE
patients (Blom, Doggen, Osanto & Rosendaal, 2005; Streiff, 2016).
Meanwhile,
thrombotic
diseases are the leading cause of non-neoplastic death in cancer
patients (Song, Rosovsky, Connors & Al-Samkari, 2019; Timp, Braekkan,
Versteeg & Cannegieter, 2013; Zamorano et al., 2016). Therefore,
coagulation prevention or anticoagulant treatment is unavoidable in
cancer patients.
For decades, anticoagulant therapy for cancer-related VTE has been
limited to vitamin K antagonists (VKAs) and heparin drugs. Recently,
direct oral anticoagulants (DOACs) have also become an option (Streiff
et al., 2020). Rivaroxaban is recommended for the treatment of
superficial vein thrombosis and VTE prophylaxis following the discharge
by the National Comprehensive Cancer Network of America in 2020 of the
clinical practice guidelines for cancer-associated venous thromboembolic
disease (Streiff et al., 2020). Similarly, the Chinese Society of
Clinical Orology has also added rivaroxaban as a recommended
anticoagulant for partial tumour patients. Additionally, data from large
randomised clinical trials also suggest that DOCAs combined with
validated risk assessment scores are a reasonable choice for the primary
thromboprophylaxis of cancer patients instead of low molecular weight
heparin (Song, Rosovsky, Connors & Al-Samkari, 2019). Importantly,
Prins et al. found that rivaroxaban is similar to the standard treatment
in terms of efficacy and safety for cancer patients, and the ease of
taking this medicine improves patient adherence, and thus it may be used
as an alternative to the standard therapy for some cancer patients
(Prins et al., 2013; Sanfilippo & Wang, 2019).
In addition to the cautious selection of anticoagulation medication to
achieve the best therapy outcomes, anticoagulant adverse effects can
also be severe and alarming, which should be comprehensively prevented.
Compared with non-cancer patients, the recurrence rate of VTE in cancer
patients is 3–4 times higher and the incidence of major bleeding is
also increased by 2–3 times (Douketis, Crowther, Foster & Ginsberg,
2001; Levitan et al., 1999; Monreal et al., 2006; Prandoni et al.,
2002). In addition to VTE, the risk of atrial fibrillation (AF) for
cancer patients was also extremely high (Onaitis, D’Amico, Zhao, O’Brien
& Harpole, 2010). An analysis showed that the occurrence of AF for
cancer patients in the 90 days after the cancer diagnosis was much
higher than for normal patients (Saliba, Rennert, Gronich, Gruber &
Rennert, 2018). And, notably, there is growing awareness that many
cancer-related factors are associated with AF, such as inflammations,
metabolic or electrolyte abnormalities and cancer therapy (Crusz &
Balkwill, 2015; Diakos, Charles, McMillan & Clarke, 2014; Farmakis,
Parissis & Filippatos, 2014; Nattel, Burstein & Dobrev, 2008; Nattel
& Harada, 2014). The prevention of stroke and systemic embolism by
using anticoagulants is one of the therapeutic cornerstones of AF
management (January et al., 2019). Therefore, cancer patients may
receive anticoagulant therapy concurrently with anti-cancer therapy.
Tyrosine
kinase inhibitors (TKIs) are a class of drugs that reduce the
phosphorylation of tyrosine protein kinases. TKIs compete with tyrosine
protein kinases for ATP phosphorylation sites to achieve targeted
anti-tumour therapy (Jiao, Bi, Ren, Song, Wang & Wang, 2018). Among
these, imatinib, sunitinib and gefitinib have been the mainstay
treatments for various solid tumours and malignant blood diseases since
their launch in 2000 (Burotto, Manasanch, Wilkerson & Fojo, 2015; Cheng
et al., 2013; Kuczynski, Lee, Man, Chen & Kerbel, 2015; Tirumani,
Jagannathan, Krajewski, Shinagare, Jacene & Ramaiya, 2013; Wertheimer
et al., 2015). Imatinib was almost the first TKI anti-tumour drug to
gain approval by the
US
Food and Drug Administration (FDA) and has become a first-line clinical
drug for gastrointestinal stromal tumours (GIST) and chronic myeloid
leukaemia (CLM) (O’Brien et al., 2003; von Mehren & Widmer, 2011).
However, due to the long treatment cycles, the safety of imatinib in
combination with other drugs is particularly important (Guilhot, 2004;
Nebot, Crettol, d’Esposito, Tattam, Hibbs & Murray, 2010). As a
multitargeted TKI, sunitinib exerts strong angiogenesis inhibitory
activity. It was approved by the FDA in 2006 as a first-line drug for
metastatic renal cell carcinoma, and it was also used as a second-line
drug for imatinib-resistant patients (Kalra, Rini & Jonasch, 2015).
Gefitinib was the first TKI to gain approval in the US and Japan for
treating advanced non-small-cell lung cancer (NSCLC), and can
significantly prolong the progression-free survival of NSCLC patients
(Dhillon, 2015). It is noteworthy that CYP3A4 accounts for a
considerable proportion of the CYP-mediated metabolism of these three
TKIs, which is similar to rivaroxaban. Indeed, it is the overlap between
the metabolic enzymes for rivaroxaban and these three TKIs that may
produce DDIs.
The status of CYP2J2 in DDI evaluation is very different to that of
CYP3A4, which may relate to the distribution characteristics of CYP2J2.
CYP2J2 is a P450 isoform that is mainly distributed in the heart and
arteries and is responsible for the metabolism of arachidonic acid; its
expression is lower in the liver. However, CYP2J2 was recently
highlighted as an emerging tumour marker. Numerous studies have reported
the high expression of CYP2J2 in various cancer cell lines, tumour
tissues and even in the liver of cancer patients, which may relate to
tumour expansion and metastasis (Allison et al., 2017; Karkhanis, Hong
& Chan, 2017). Therefore, inhibiting CYP2J2 may be a novel and
effective approach for cancer therapy (Allison et al., 2017). However,
safety assessment data on medication combinations are lacking, so the
related roles of CYP2J2 are unknown.
Imatinib, sunitinib and gefitinib have been widely applied for patients
with solid tumours in clinical practice. Thus, the comitant
administration of rivaroxaban with these three TKIs has a profound
combination foundation in the treatment of cancer patients. However, the
safety of this combination deserves further attention as assessment data
on the safety of rivaroxaban with TKIs is limited: more relevant and
detailed pharmacokinetics measurements are required. The present study
assessed the DDI risk of the combination of rivaroxaban with the three
TKIs by in vitro enzyme assays. Importantly, the investigation was
mainly performed on CYP2J2 and CYP3A4 to comprehensively explore their
reversible and time-dependent inactivation behaviours. Finally, the in
vivo DDI risk of the combination of rivaroxaban with the three TKIs was
estimated according to detailed pharmacokinetic parameters of cancer
patients, producing direct evidence to inform clinical medication safety
assessment.