Seville orange juice-felodipine interaction: Comparison with dilute grapefruit juice and involvement of furocoumarins

Objective: Our objective was to determine whether Seville orange juice produces a grapefruit juice-like interaction with felodipine and whether bergamottin, 6',7'-dihydroxybergamottin, or other furocoumarins are involved. Methods: In a randomized three-way crossover design, 10 volunteers received a felodipine 10-mg extended-release tablet with 240 mt of Seville orange juice, dilute grapefruit juice (that contained equivalent total molar concentrations of bergamottin plus 6',7'-dihydroxybergamottin), or common orange juice (negative control). The pharmacokinetics of felodipine and its dehydrofelodipine metabolite were determined. Juice concentrations of furocoumarins were measured. CYP3A4 inhibitory activity of newly identified furocoumarins was assessed. Results: The felodipine area under the plasma concentration-time curve was increased by 76% and 93% after Seville orange juice and grapefruit juice ingestion, respectively, compared with common orange juice. The effects of Seville orange juice and grapefruit juice were similar in that the felodipine maximum concentration was augmented while the terminal elimination half-life was unchanged and the dehydrofelodipine area under the plasma concentration time-curve was increased, but the dehydrofelodipine-felodipine area under the plasma concentration-time curve ratio was reduced. Bergamottin and 6',7'-dihydroxybergamottin concentrations were 5 and 36 mu mol/L, respectively, in Seville orange juice and were 16 and 23 mu mol/L, respectively, in dilute grapefruit juice. A newly identified furocoumarin, bergapten, was detected only in Seville orange juice (31 mu mol/L), and it was found to be a mechanism-based inhibitor of recombinant CYP3A4. Relative to the control, 6',7'-dihydroxybergamottin (10 mu mol/L) inhibited CYP3A4 activity in cultured intestinal epithelial cells by 93%, whereas bergapten (10 mu mol/L) inhibited the activity by only 34%. Conclusions: Seville orange juice and grapefruit juice interact with felodipine by a common mechanism, which is probably inactivation of intestinal CYP3A4. Bergamottin and 6',7'-dihydroxybergamottin may be "marker substances" in foods for this interaction. The lack of interaction between Seville orange juice and cyclosporine (INN, ciclosporin) suggests that grapefruit juice may also inhibit intestinal P-glycoprotein, whereas Seville orange juice may selectively "knock out" intestinal CYP3A4.