Predictions of metabolic drug-drug interactions using physiologically based modelling: Two cytochrome P450 3A4 substrates coadministered with ketoconazole or verapamil

Clin Pharmacokinet. 2010 Apr;49(4):239-58. doi: 10.2165/11318130-000000000-00000.


Nowadays, evaluation of potential risk of metabolic drug-drug interactions (mDDIs) is of high importance within the pharmaceutical industry, in order to improve safety and reduce the attrition rate of new drugs. Accurate and early prediction of mDDIs has become essential for drug research and development, and in vitro experiments designed to evaluate potential mDDIs are systematically included in the drug development plan prior to clinical assessment. The aim of this study was to illustrate the value and limitations of the classical and new approaches available to predict risks of DDIs in the research and development processes. The interaction of cytochrome P450 (CYP) 3A4 inhibitors (ketoconazole and verapamil) with midazolam was predicted using the inhibitor concentration/inhibition constant ([I]/K(i)) approach, the static approach with added variability (Simcyp(R)), and whole-body physiologically based pharmacokinetic (WB-PBPK) modelling (acslXtreme(R)). Then an in-house reference drug was used to challenge the different approaches based on the midazolam experience. Predicted values (pharmacokinetic parameters, the area under the plasma concentration-time curve [AUC] ratio and plasma concentrations) were compared with observed values obtained after intravenous and oral administration in order to assess the accuracy of the prediction methods. With the [I]/K(i) approach, the interaction risk was always overpredicted for the midazolam substrate, regardless of its route of administration and the coadministered inhibitor. However, the predictions were always satisfactory (within 2-fold) for the reference drug. For the Simcyp(R) calculations, two of the three interaction results for midazolam were overpredicted, both when midazolam was given orally, whereas the prediction obtained when midazolam was administered intravenously was satisfactory. For the reference drug, all predictions could be considered satisfactory. For the WB-PBPK approach, all predictions were satisfactory, regardless of the substrate, route of administration, dose and coadministered inhibitor. DDI risk predictions are performed throughout the research and development processes and are now fully integrated into decision-making processes. The regulatory approach is useful to provide alerts, even at a very early stage of drug development. The 'steady state' approach in Simcyp(R) improves the prediction by using physiological knowledge and mechanistic assumptions. The DDI predictions are very useful, as they provide a range of AUC ratios that include individuals at the extremes of the population, in addition to the 'average tendency'. Finally, the WB-PBPK approach improves the predictions by simulating the concentration-time profiles and calculating the related pharmacokinetic parameters, taking into account the time of administration of each drug - but it requires a good understanding of the absorption, distribution, metabolism and excretion properties of the compound.

MeSH terms

  • Algorithms
  • Area Under Curve
  • Cytochrome P-450 CYP3A
  • Cytochrome P-450 CYP3A Inhibitors*
  • Drug Interactions
  • Humans
  • Ketoconazole / pharmacokinetics*
  • Metabolic Clearance Rate
  • Midazolam / pharmacokinetics
  • Models, Biological*
  • Monte Carlo Method
  • Verapamil / pharmacokinetics*


  • Cytochrome P-450 CYP3A Inhibitors
  • Verapamil
  • Cytochrome P-450 CYP3A
  • CYP3A4 protein, human
  • Midazolam
  • Ketoconazole