In Situ Intestinal Perfusion in Knockout Mice Demonstrates Inhibition of Intestinal P-Glycoprotein by Ritonavir Causing Increased Darunavir Absorption

Darunavir is a second-generation protease inhibitor designed to have antiviral efficacy against HIV-1 with multiple resistance mutations to protease inhibitors. It is always coadministered with a subtherapeutic dose of ritonavir. It has been shown that darunavir and ritonavir are substrates of P-glycoprotein (P-gp). We explored the contribution of P-gp to the transport characteristics of darunavir (up to 100 mu M) using Caco-2 monolayers and the recently developed in situ intestinal perfusion technique using wild-type and mdr1a/1b(-/-) mice. We observed that, in vitro, P-gp has a modulatory effect on the absorption of darunavir, even at a concentration of 100 mu M (efflux ratio = 25). Simulated intestinal fluids partially inhibited P-gp functionality, which was further inhibited by adding the P-gp inhibitors verapamil, 6-[(2S,4R,6E)-4-methyl-2-(methylamino)-3-oxo-6-octenoic acid] cyclosporine D (PSC833), N-(4-[2-(1,2,3,4-tetrahydro-6,7-dimethoxy-2-isoquinolinyl)ethyl]-phenyl)-9,10-dihydro-5-methoxy-9-oxo-4-acridine carboxamide (GF120918), or ritonavir. Using the in situ intestinal perfusion technique, we demonstrated that coperfusion with ritonavir resulted in a similar apparent permeability coefficient to that observed using P-gp knockout mice, which was 2.7-fold higher than in control mice. We conclude that, in mice, even at a relevant intraluminal concentration of darunavir, P-gp has a modulatory effect on the absorption of darunavir. However, this P-gp-mediated darunavir transport is inhibited when it is combined with ritonavir.