Population pharmacokinetic and pharmacodynamic modelling of the effects of nicorandil in the treatment of acute heart failure

Abstract

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • Nicorandil injection is used for unstable angina and for acute heart failure in Japan. • The pharmacokinetics of nicorandil following oral administration have been described in healthy subjects. WHAT THIS STUDY ADDS • This paper describes the differences in nicorandil pharmacokinetics between healthy subjects and acute heart failure patients. • A population pharmacokinetic‐pharmacodynamic model for nicorandil in acute heart failure patients is described using pulmonary artery wedge pressure as the biomarker. • A rational guide for initial dosing of nicorandil to achieve a target effect on pulmonary artery wedge pressure was based on pharmacokinetic and pharmacodynamic principles. AIMS The aims of the study were 1) to evaluate the pharmacokinetics of nicorandil in healthy subjects and acute heart failure (AHF) patients and 2) to evaluate the exposure‐response relationship with pulmonary arterial wedge pressure (PAWP) in AHF patients and to predict an appropriate dosing regimen for nicorandil. METHODS Based on the data from two healthy volunteer and three AHF patient studies, models were developed to characterize the pharmacokinetics and pharmacodynamics of nicorandil. PAWP was used as the pharmacodynamic variable. An asymptotic exponential disease progression model was used to account for time dependent changes in PAWP that were not explained by nicorandil exposure. The modelling was performed using NONMEM version V. RESULTS The pharmacokinetics of nicorandil were characterized by a two‐compartment model with linear elimination. CL, V1 and V2 in AHF patients were 1.96, 1.39 and 4.06 times greater than in healthy subjects. Predicted plasma concentrations were assumed to have an immediate concentration effect relationship on PAWP. An inhibitory Emax model with Emax of −11.7 mmHg and EC50 of 423 µg l−1 was considered the best relationship between nicorandil concentrations and PAWP. PAWP decreased independently of nicorandil exposure. This drug independent decline was described by an asymptotic decrease of 6.1 mmHg with a half‐life of 5.3 h. CONCLUSIONS AHF patients have higher clearance and initial distribution volume of nicorandil compared with healthy subjects. The median target nicorandil concentration to decrease PAWP by 30% is predicted to be 748 µg l−1, indicating that a loading dose of 200 µg kg−1 and a maintenance dose of 400 µg kg−1 h−1 would be appropriate for the initial treatment of AHF.

The influence of heart failure on the pharmacokinetics of cardiovascular and non‐cardiovascular drugs: a critical appraisal of the evidence

“…A total of 59 studies (49 on cardiovascular drugs) investigating 36 drugs (31 cardiovascular) were identified (Tables ). Twelve studies were published in the period 1970–1979 , 20 in the period 1980–1989 , 12 in the period 1990–1999 , 10 in the period 2000–2009 , and five in the period 2010–2018 .…”

“…A total of 59 studies (49 on cardiovascular drugs) investigating 36 drugs (31 cardiovascular) were identified (Tables 1-6). Twelve studies were published in the period 1970-1979 [37][38][39][40][41][42][43][44][45][46][47][48], 20 in the period 1980-1989 [49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67][68], 12 in the period 1990-1999 [69][70][71][72][73][74][75][76][77][78][79][80], 10 in the period 2000-2009 [81][82][83][84][85]…”

“…HF did not significantly affect the pharmacokinetics of the calcium channel blocker nifedipine, the endothelin receptor antagonist bosentan, and the direct vasodilating agent hydralazine, drugs that are also significantly metabolized in the liver (Table S1) [54,55,93]. By contrast, patients with HF had a significantly greater volume of distribution (+39%) and higher clearance (+94%) of the vasodilator nicorandil, administered intravenously, when compared to controls [84]. Studies investigating the effects of HF on the pharmacokinetics of nitrates showed reduced peak concentrations (À28%) and a significantly longer time to reach peak concentrations (+72%) and, to a lesser extent, elimination half-life (+29%) with isosorbide-5-mononitrate [74].…”

“…No n/a n/a n/a n/a n/a n/a i.v. infusion [84] Population PK: n = 105, age n/a, 76M/29FHF subgroup: n = 94, NYHA II-IV, age n/a, 65M/29F n/a n/a n/a n/a n/a n/a ↑ (+39%)…”

Should Nicorandil Infusion Be Adapted in Dialysis‐Dependent Patients Undergoing Continuous Renal Replacement Therapy After Cardiac Surgery?

“…First, although patients with LVEF (<40%) were excluded in this study, a previous report showed that nicorandil clearance nearly doubled in patients with acute heart failure compared with healthy subjects (21). First, although patients with LVEF (<40%) were excluded in this study, a previous report showed that nicorandil clearance nearly doubled in patients with acute heart failure compared with healthy subjects (21).…”