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Ketoconazole Increases Fingolimod Blood Levels in a Drug Interaction via CYP4F2 Inhibition

From Novartis Pharmaceuticals, Basel, Switzerland, and East Hanover, New Jersey (Dr Kovarik, Mr Dole, Dr Riviere, Dr Pommier, Mr Maton, Dr Jin, Dr Schmouder), and Clinical Pharmacology of Miami, Inc, Miami, Florida (Dr Lasseter).

The sphingosine-1-phosphate receptor modulator fingolimod is predominantly hydroxylated by cytochrome CYP4F2. In vitro experiments showed that ketoconazole significantly inhibited the oxidative metabolism of fingolimod by human liver microsomes and by recombinant CYP4F2. The authors used ketoconazole as a putative CYP4F2 inhibitor to quantify its influence on fingolimod pharmacokinetics in healthy subjects. In a 2-period, single-sequence, crossover study, 22 healthy subjects received a single 5-mg dose of fingolimod in period 1. In period 2, subjects received ketoconazole 200 mg twice daily for 9 days and a single 5-mg dose of fingolimod coadministered on the 4th day of ketoconazole treatment. Ketoconazole did not affect fingolimod t_max or half-life, but there was a weak average increase in C_max of 1.22-fold (90% confidence interval, 1.15-1.30). The AUC over the 5 days of ketoconazole coadministration increased 1.40-fold (1.31-1.50), and the full AUC to infinity increased 1.71-fold (1.53-1.91). The AUC of the active metabolite fingolimod-phosphate was increased to a similar extent by 1.67-fold (1.50-1.85). Ketoconazole predose plasma levels were not altered by fingolimod. The magnitude of this interaction suggests that a proactive dose reduction of fingolimod is not necessary when adding ketoconazole to a fingolimod regimen. The clinician, however, should be aware of this interaction and bear in mind the possibility of a fingolimod dose reduction based on clinical monitoring.

Key Words: Immunomodulators • fingolimod • ketoconazole • drug interactions • CYP4F2

Address for reprints: John M. Kovarik, PhD, FCP, Novartis Pharma, Building WSJ 210.427, 4002 Basel, Switzerland.

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