ABSTRACT:Liver and bile secretion can be an important first-pass and clearance route for drug compounds and also the site of several drug-drug interactions. In the clinical program for ximelagatran development, an unexpected effect of erythromycin on the pharmacokinetics of the direct thrombin inhibitor ximelagatran and its metabolites was detected. This interaction was believed to be mediated by inhibition of drug transporters, which normally extrude the drug into the bile. Previous Caco-2 cell experiments indicated the involvement of an active efflux mechanism for ximelagatran, hydroxy-melagatran, and melagatran possibly mediated by P-glycoprotein (P-gp). However, the inhibitors used may not have been specific enough and the possibility that transporters other than P-gp were important in the Caco-2 cell assay cannot be excluded. In this study we used RNA interference, a post-transcriptional gene silencing mechanism in which mRNA is degraded in a sequence-specific manner, to specifically knock down P-gp or multidrug resistance-associated protein 2 (MRP2) transporters in Caco-2 cells. The data obtained from bidirectional transport studies in these cells indicate a clear involvement of P-gp but not of MRP2 in the transport of ximelagatran, hydroxy-melagatran, and melagatran across the apical cell membrane. The present study shows that short hairpin RNA Caco-2 cells are a valuable tool to investigate the contribution of specific transporters in the transcellular transport of drug molecules and to predict potential sites of pharmacokinetic interactions. The results also suggest that inhibition of hepatic P-gp is involved in the erythromycin-ximelagatran interaction seen in clinical studies.The direct thrombin inhibitor ximelagatran was envisaged to have a low potential for pharmacokinetic drug-drug interactions (DDIs) based on the preclinical information showing that ximelagatran, its intermediate metabolites, and melagatran are neither substrates nor inhibitors of the major cytochrome P450 isoenzymes (Bredberg et al., 2003). The preclinical results were supported by the results from three specific healthy volunteer studies showing no clinically significant DDIs between ximelagatran and diclofenac, diazepam, or nifedipine when coadministered simultaneously (Bredberg et al., 2003). The phase I DDI study showing a clear interaction with erythromycin, therefore, came as a surprise. Melagatran area under the curve increased by 82%, whereas ximelagatran plasma levels seemed to be essentially unchanged. Ximelagatran is bioconverted to melagatran via two intermediates, hydroxy-melagatran and ethyl-melagatran (Fig. 1), and an elevation in the plasma concentrations was seen for both intermediates, after coadministration with erythromycin (Eriksson et al., 2006).Several in vivo and in vitro studies have been performed to investigate the nature of the erythromycin-ximelagatran interaction (Eriksson et al., 2006; Sjö din et al., 2008). The pharmacokinetic profile in humans indicated that the elevation of ximelagatran and its m...