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.