Drug-drug interactions are important and accordingly are a major issue in the advancement of new chemical entities to patients. In one study (Montané et al., 2018), drug-related deaths accounted for 7% of all deaths in hospital settings. Drug-drug interactions are an issue in this regard. Although some pharmacodynamic issues are involved, a large fraction of the drug-drug interactions is pharmacokinetic in nature.A general overview of the interactions of a chemical with an enzyme is shown in Fig. 1A, where an enzyme involved in the metabolism of a drug is considered. The drug is converted to a product, often called a metabolite. With respect to the parent drug molecule, the product may have unaltered pharmacological activity, lose some or all of its pharmacological activity, be even more active, or be toxic. In the interactions of two drugs, one is sometimes termed the "perpetrator" and one the "victim" (Fig. 1B). In some cases, drug interaction due to enhanced metabolism by induction or allosteric activation may be seen and have clinical consequences (Bolt et al., 1977), but the focus here will be on competitive and irreversible inhibitors that attenuate drug metabolism (as "perpetrators").Recently Yu et al. (2018) evaluated drug-drug interactions in 103 recent drug approvals by the United States Food and Drug Administration (FDA). Of these, 45 were involved as victims (substrates) in interactions with marketed drugs (perpetrators). The therapeutic classes are shown in Fig. 2A, with cancer treatments accounting for more than 1/4. The enzymes involved are primarily cytochrome P450 and transporter enzymes (Fig. 2B), with P450 3A4/5 involved in ~2/3 of the interactions. Of the 103 new drugs, 20 were acting as perpetrators to some extent (Yu et al., 2018), with P450 3A4/5 and P-glycoprotein again being the most prominent enzymes (Fig. 1B). Accordingly, this review will focus on issues of inhibition of P450 3A4 (In general P450 3A4 and 3A5 have similar substrate specificity and are sensitive to the same inhibitors, with some important exceptions (Hardy et al., 2014;Zhu et al., 2014;Kramlinger et al., 2015), but many experiments with drugs were done only with P450 3A4-or 3A4 and 3A5 were not discriminated-and will be referred to as 3A4 in that context).
BACKGROUND ON P450SP450s enzymes are the main catalysts involved in the oxidation of chemicals in general (Rendic and Guengerich, 2015), including drugs. The same is true for involvement in Please cite this article in press as: Guengerich, Inhibition of Cytochrome P450 Enzymes by Drugs-Molecular Basis and Practical Applications, Biomol. Ther.