Download SLCO1B1 polymorphism markedly affects the pharmacokinetics of

Original article 873
SLCO1B1 polymorphism markedly affects the
pharmacokinetics of simvastatin acid
Marja K. Pasanen, Mikko Neuvonen, Pertti J. Neuvonen and Mikko Niemi
Background and objective Organic anion transporting
polypeptide 1B1 (OATP1B1) is an uptake transporter
located at the sinusoidal membrane of human hepatocytes.
This study aimed to investigate the effects of genetic
polymorphism in the SLCO1B1 gene encoding OATP1B1
on the pharmacokinetics of simvastatin.
Methods Four healthy volunteers with the homozygous
SLCO1B1 c.521CC genotype, 12 with the heterozygous
c.521TC genotype and 16 with the homozygous c.521TT
genotype (controls) were recruited. Each study participant
ingested a single 40-mg dose of simvastatin. Plasma
concentrations of simvastatin (inactive lactone) and its
active metabolite simvastatin acid were measured for 12 h.
Results The AUC0–N of simvastatin acid was 120 and
221% higher in participants with the SLCO1B1 c.521CC
genotype than in those with the c.521TC and c.521TT
(reference) genotypes, respectively (P < 0.001). The Cmax of
simvastatin acid was 162 and 200% higher in participants
with the c.521CC genotype than in those with the c.521TC
and c.521TT genotypes (P < 0.001). The Cmax of simvastatin
acid occurred earlier in participants with the c.521CC and
c.521TC genotypes than in those with the c.521TT genotype
(P < 0.05). No association existed between the SLCO1B1
genotype and the elimination half-life of simvastatin acid.
Moreover, no statistically significant association was seen
between the SLCO1B1 genotype and the pharmacokinetics
of simvastatin lactone.
Introduction
Simvastatin is a 3-hydroxy-3-methylglutaryl-coenzyme A
(HMG-CoA) reductase inhibitor used in the treatment
of hypercholesterolemia [1]. It reduces cardiovascular
morbidity and mortality in high-risk patients [2].
Simvastatin is administered as an inactive lactone
prodrug, which undergoes reversible non-enzymatic
and carboxylesterase-mediated conversion in plasma, liver
and intestinal mucosa to simvastatin acid, the active
metabolite of simvastatin [1,3]. Simvastatin acid and
other simvastatin-derived active metabolites inhibit the
conversion of HMG-CoA to mevalonate, which is the rate
limiting step in cholesterol biosynthesis [4]. Inhibition of
the HMG-CoA reductase in the liver increases the
expression of low-density lipoprotein (LDL) receptors
in the hepatocyte plasma membrane, enhancing the
removal of LDL particles from blood and reducing plasma
total and LDL cholesterol concentrations.
Conclusions SLCO1B1 polymorphism markedly affects the
pharmacokinetics of active simvastatin acid, but has no
significant effect on parent simvastatin. Raised plasma
concentrations of simvastatin acid in patients carrying the
SLCO1B1 c.521C variant allele may enhance the risk of
systemic adverse effects during simvastatin treatment. In
addition, reduced uptake of simvastatin acid by OATP1B1
into the liver in patients with the c.521C allele could reduce
its cholesterol-lowering efficacy. Pharmacogenetics and
c 2006 Lippincott Williams &
Genomics 16:873–879 Wilkins.
Pharmacogenetics and Genomics 2006, 16:873–879
Keywords: OATP1B1, organic anion transporting polypeptide,
pharmacogenetics, pharmacokinetics, simvastatin, simvastatin acid,
SLCO1B1
Department of Clinical Pharmacology, University of Helsinki and Helsinki
University Central Hospital, Helsinki, Finland.
Correspondence and requests for reprints to Mikko Niemi, MD, Department of
Clinical Pharmacology, Helsinki University Central Hospital, P.O. Box 340,
FIN-00029 HUS, Finland.
Fax: + 358 9 471 74039; e-mail: [email protected]
Sponsorship: This study was supported by grants from the Helsinki University
Central Hospital Research Fund (Helsinki, Finland) and the Sigrid Juselius
Foundation (Helsinki).
Received 2 May 2006 Accepted 20 June 2006
Large interindividual variability exists in the plasma
concentrations of simvastatin and in its efficacy and risk
of adverse effects. Myopathy is a relatively common
adverse effect of statins, whereas the serious rhabdomyolysis is rare [5,6]. The incidence of myopathy and
rhabdomyolysis increases along with increased plasma
concentrations of statins, and particularly when statins
are used concomitantly with compounds that inhibit their
metabolism or plasma membrane transport [7,8].
Simvastatin undergoes extensive first-pass metabolism in
the intestinal wall and the liver, and its systemic
bioavailability is less than 5% [3]. Oxidative metabolism
of simvastatin lactone in the liver is catalyzed mainly by
cytochrome P450 (CYP) 3A4, with CYP3A5 contributing
to a lesser extent [9]. Active simvastatin acid is also
metabolized mainly by CYP3A4, with contribution from
CYP3A5, CYP2C8 and UDP-glucuronosyltransferase
c 2006 Lippincott Williams & Wilkins
1744-6872 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
874 Pharmacogenetics and Genomics 2006, Vol 16 No 12
[10,11]. CYP3A4 inhibitors, such as itraconazole, verapamil, erythromycin and grapefruit juice, markedly elevate
the plasma concentrations of both simvastatin and
simvastatin acid [12–14]. In addition, genetic polymorphism in CYP3A5 was associated with simvastatin efficacy
in one study [15].
Organic anion transporting polypeptide 1B1 (OATP1B1)
is a solute carrier expressed on the sinusoidal membrane
of human hepatocytes [16–18]. It facilitates the hepatic
uptake of many endogenous and foreign compounds, such
as estrogen conjugates, bile acids and statins [16–24]. A
common single nucleotide polymorphism (SNP) in
SLCO1B1, c.521T > C (p.Val174Ala), has been associated
with reduced activity of OATP1B1 in vitro [23,25] and
markedly increased plasma concentrations of pravastatin,
rosuvastatin and pitavastatin in vivo in humans [26–30].
In one study performed in vitro, simvastatin lactone was
not transported by OATP1B1 [23], but there seem to be
no studies directly investigating whether simvastatin acid
is a substrate of OATP1B1. Simvastatin acid, however,
strongly inhibits OATP1B1-mediated uptake of pravastatin in vitro, suggesting that it may also be a substrate for
OATP1B1 [17,31]. As SLCO1B1 polymorphism markedly
affects the pharmacokinetics of several statins, we
wanted to investigate the effects of variant SLCO1B1
Table 1
genotypes on the pharmacokinetics of simvastatin and
simvastatin acid in a prospective genotype panel study
controlling for CYP3A5 polymorphism.
Methods
Study participants
A total of 32 young healthy Caucasian volunteers
participated in the study after giving written informed
consent. The study participants had been genotyped for
SLCO1B1 SNPs by TaqMan allelic discrimination with an
Applied Biosystems 7300 Real-Time PCR system (Applied Biosystems, Foster City, California, USA) as
described previously [32]. In addition, they were
genotyped for the CYP3A5*3 (g.6986A > G) allele as
described previously [15]. As the CYP3A5 genotype has
been associated with the efficacy of simvastatin [15], only
participants with the CYP3A5 non-expressor genotype
(CYP3A5*3/*3) were recruited. The participants were
selected on the basis of the SLCO1B1 c.521T > C SNP as
well as the g. – 11187G > A, g. – 10499A > C and
c.388A > G SNPs, by which the four major Caucasian
haplotypes containing the c.521C allele (*5, *15, *16 and
*17) can be distinguished [28,32]. The participants were
allocated into one of three groups according to the
genotype. Haplotypes were assigned as described previously (Table 1) [32]. The control group included
Genetic background of the study participants
SLCO1B1
Participant no.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28b
29
30
31
32
g. – 11187G > A
g. – 10499A > C
c.388A > G
c.521T > C
Diplotypea
GA
GA
GG
GG
GA
GA
GA
GA
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
GG
AC
AC
CC
AA
AA
AA
AA
AA
AC
AC
AC
AC
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
GG
GG
GG
AG
AG
AG
GG
AG
GG
AG
GG
AG
GG
AG
GG
AG
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
AA
CC
CC
CC
CC
TC
TC
TC
TC
TC
TC
TC
TC
TC
TC
TC
TC
TT
TT
TT
TT
TT
TT
TT
TT
TT
TT
TT
TT
TT
TT
TT
TT
SLCO1B1*16/*17
SLCO1B1*16/*17
SLCO1B1*16/*16
SLCO1B1*5/*15
SLCO1B1*1A/*17
SLCO1B1*1A/*17
SLCO1B1*1B/*17
SLCO1B1*1A/*17
SLCO1B1*1B/*16
SLCO1B1*1A/*16
SLCO1B1*1B/*16
SLCO1B1*1A/*16
SLCO1B1*1B/*15
SLCO1B1*1A/*15
SLCO1B1*1B/*15
SLCO1B1*1A/*15
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
SLCO1B1*1A/*1A
a
Diplotype prediction is based on the g. – 11187G > A, g. – 10499A > C, c.388A > G and c.521T > C single nucleotide polymorphisms: *1A haplotype is GAAT, *1B is
GAGT, *5 is GAAC, *15 is GAGC, *16 is GCGC, *17 is AAGC.
b
This participant was a tobacco smoker.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
SLCO1B1 polymorphism and simvastatin Pasanen et al. 875
16 participants (eight women, eight men) with the
homozygous reference genotype at each position
(c.521TT group). Their mean ± SD age was 23 ± 2 years,
height 174 ± 9 cm and weight 68 ± 10 kg. The second
group consisted of 12 participants (five women, seven
men) heterozygous for the c.521T > C SNP (c.521TC
group). Their mean ± SD age was 24 ± 4 years, height
174 ± 9 cm and weight 69 ± 8 kg. The third group
comprised four participants (one woman, three men)
with the homozygous c.521CC genotype (c.521CC
group). Their mean ± SD age was 23 ± 2 years, height
180 ± 8 cm and weight 84 ± 8 kg. The participants were
ascertained to be healthy by medical history, physical
examination and routine laboratory tests before they were
entered in the study. One participant with the c.521TT
genotype was a tobacco smoker and none used any
continuous medication.
Study design
The study protocol was approved by the Coordinating
Ethics Committee of the Helsinki and Uusimaa Hospital
District and by the National Agency for Medicines.
Following an overnight fast, the participants ingested a
single 40-mg dose of simvastatin (Zocor, Merck Sharp &
Dohme, Haarlem, The Netherlands) with 150 ml water at
08:00 h. A standard warm meal was served 4 h after
simvastatin ingestion and a standard light meal after 7
and 10 h. Timed blood samples (5–10 ml each) were
drawn before and 0.5, 1, 1.5, 2, 3, 4, 5, 7, 9 and 12 h after
simvastatin ingestion into tubes that contained ethylenediaminetetraacetic acid and were placed on ice
immediately after sampling. Plasma was separated within
30 min after blood sampling and stored at – 701C until
analysis. Use of other drugs was prohibited for 1 week and
use of grapefruit products was prohibited for 3 days
before simvastatin administration.
Determination of plasma simvastatin and simvastatin
acid concentrations
Plasma simvastatin and simvastatin acid concentrations
were quantified by liquid chromatography-ion spray
tandem mass spectrometry using the PE Sciex API
3000 LC/MS/MS system (Sciex Division of MDS Inc.,
Toronto, Ontario, Canada) as described previously
[33,34]. The limit of quantification was 0.05 ng/ml for
simvastatin and 0.1 ng/ml for simvastatin acid. The
between-day coefficients of variation were 4.1% at
0.1 ng/ml, 5.2% at 1.0 ng/ml and 3.2% at 50 ng/ml of
simvastatin (n = 4), and 9.9% at 0.1 ng/ml, 7.3% at 1.0 ng/
ml and 7.0% at 50 ng/ml of simvastatin acid (n = 4).
Pharmacokinetics
The pharmacokinetics of simvastatin and simvastatin acid
were characterized by the peak concentration in plasma
(Cmax), time to Cmax (tmax), elimination half-life (t1/2) and
area under the plasma concentration–time curve from 0
to 12 h (AUC0–12) and from 0 h to infinity (AUC0–N).
The terminal log-linear part of each concentration–time
curve was identified visually, and the elimination rate
constant (ke) was determined from log-transformed data
with linear regression analysis. The t1/2 was calculated by
the equation t1/2 = ln 2/ke. AUC was calculated by a
combination of the linear and log-linear trapezoidal rules,
with extrapolation to infinity, when appropriate, by
division of the last measured concentration by ke.
Statistical analysis
Results are expressed as mean ± SD in the text and tables
and, for clarity, as mean ± SEM in Fig. 1. The pharmacokinetic variables of simvastatin and simvastatin acid
between the SLCO1B1 c.521TT, c.521TC and c.521CC
genotype groups were compared using analysis of variance
and pairwise testing with the Tukey test. The tmax data
were analyzed by the Kruskal–Wallis test and pairwise
testing with the Mann–Whitney U-test using the Bonferroni correction. The data were analyzed with the statistical
program SPSS 11.0 for Windows (SPSS Inc., Chicago,
Illinois, USA). On the basis of previous data on the
pharmacokinetics of simvastatin [12], the number of
participants in each genotype group was estimated to be
sufficient to detect a 50% larger AUC0–N of simvastatin or
simvastatin acid in participants with the c.521TC genotype than in those with the c.521TT genotype, and a 100%
larger AUC0–N in participants with the c.521CC genotype
than in those with the c.521TT genotype with a power of
at least 80% (a-level 5%). Differences were considered
statistically significant at a P value less than 0.05.
Results
The SLCO1B1 genotype was significantly associated with
the pharmacokinetics of simvastatin acid, but not with
those of the parent simvastatin lactone (Fig. 1a–c, Table
2). The simvastatin acid Cmax and AUC0–N values of one
participant (no. 6) with the c.521TC genotype were more
than 3 SDs above the respective mean values (Fig. 2a and
c), and the participant was excluded from statistical
analysis as an outlier. In the participants with the
SLCO1B1 c.521CC genotype, the mean AUC0–N of
simvastatin acid was 120 and 221% higher, respectively,
than in the participants with the c.521TC and c.521TT
(reference) genotypes (P < 0.001). The mean Cmax of
simvastatin acid was 162 and 200% higher in the
participants with the c.521CC genotype than in those
with the c.521TC and c.521TT genotypes (P < 0.001). In
addition, the tmax of simvastatin acid was significantly
shorter in the participants with the c.521TC and c.521CC
genotypes than in those with the c.521TT genotype
(P < 0.05). The SLCO1B1 genotype had no statistically
significant effect on the elimination t1/2 of simvastatin
acid (Fig. 2b, Table 2).
The mean AUC0–N ratio (simvastatin acid/simvastatin)
was 1.5 ± 0.4 in the participants with the c.521CC
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
876 Pharmacogenetics and Genomics 2006, Vol 16 No 12
genotype, 0.7 ± 0.4 in those with the c.521TC genotype
and 0.7 ± 0.2 in those with the c.521TT genotype
(c.521CC vs. c.521TC, P = 0.001; c.521CC vs. c.521TT,
P < 0.001) (Fig. 1c). A tendency towards higher Cmax and
AUC0–N of simvastatin lactone was observed in the
participants with the homozygous c.521CC genotype
than in the reference group, but the differences were not
statistically significant. When the outlier participant was
included in the analysis, other differences remained
statistically significant except for those in the AUC0–N
ratio and the simvastatin acid Cmax between the c.521CC
and c.521TC groups (data not shown).
Fig. 1
(a)
Simvastatin (ng/ml)
12
10
8
6
4
2
0
0
1
2
3
4
5
7
Time (h)
9
12
(b) 7
Simvastatin acid (ng/ml)
6
5
4
3
2
1
0
0
1
2
3
4
5
7
Time (h)
9
12
(c) 7
The Cmax and AUC0–N of simvastatin lactone varied
eight-fold and 12-fold between individual participants
and those of simvastatin acid varied 25-fold and 16-fold.
The variability in the Cmax and AUC0–N of simvastatin
acid, however, was considerably smaller within the
SLCO1B1 c.521TT (six-fold and four-fold) or c.521CC
(1.5-fold and 1.7-fold) genotype groups (Fig. 2a–c). The
variability was large within the c.521TC group (17-fold
and 14-fold), but this was because the outlier participant
had exceptionally high values.
Discussion
6
Simvastatin acid/simvastatin
No statistically significant differences were seen in the
pharmacokinetic variables of simvastatin acid between
c.521TC heterozygous participants with different
SLCO1B1 haplotypes. The mean ± SD AUC0–N of
simvastatin acid was 25.0 ± 15.3 ng h/ml in c.521TC
heterozygotes with the *15 haplotype, 19.0 ± 4.0 ng h/ml
in those with the *16 haplotype and 36.5 ± 43.1 ng h/ml
in those with the *17 haplotype (including the outlier)
(P = 0.650).
5
4
3
2
1
0
0
1
2
3
4
5
7
9
12
Time (h)
Mean ± SEM plasma concentrations of simvastatin (a) and simvastatin
acid (b), and the plasma simvastatin acid/simvastatin ratio (c) after a single
40-mg oral dose of simvastatin in 31 healthy Caucasians in relation to the
SLCO1B1 c.521T > C SNP. For clarity, some error bars have been
omitted. Open squares indicate individuals with the c.521TT genotype
(n = 16); solid squares indicate individuals with the c.521TC genotype
(n = 11); solid triangles indicate individuals with the c.521CC genotype
(n = 4). Data for the c.521TC group are calculated from 11 participants,
because one of the original 12 participants was excluded as an outlier.
This study shows that SLCO1B1 polymorphism has a
marked effect on the plasma pharmacokinetics of active
simvastatin acid, but not on those of the parent
simvastatin lactone. The mean AUC and Cmax of
simvastatin acid were about three-fold in participants
with the SLCO1B1 c.521CC genotype as compared with
those in participants with the c.521TT reference
genotype. This finding supports the idea that simvastatin
acid is a substrate of OATP1B1 and that it needs active
transport in order to penetrate the hepatocyte plasma
membrane. In contrast, the AUC and Cmax of the parent
simvastatin lactone were only slightly and not statistically
significantly different between participants with different
SLCO1B1 genotypes. This indicates that simvastatin
lactone either penetrates the hepatocyte plasma membrane via passive diffusion or that an uptake transporter
other than OATP1B1 mediates its hepatic uptake.
Molecular size, lipophilicity and charge are the major
determinants of permeability of a lipid membrane to a
drug. The molecular weight of simvastatin acid is 437 and
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
SLCO1B1 polymorphism and simvastatin Pasanen et al. 877
Pharmacokinetic variables of a single 40-mg oral dose of simvastatin in relation to SLCO1B1 polymorphism in 31 healthy
Caucasians
Table 2
SLCO1B1 genotype
Simvastatin
c.521TT (n = 16)
c.521TC (n = 11)a
c.521CC (n = 4)
Simvastatin acid
c.521TT (n = 16)
c.521TC (n = 11)a
c.521CC (n = 4)
Cmax(ng/ml)
8.9 ± 4.7
10.2 ± 4.9
13.0 ± 3.7
2.2 ± 0.9
3.0 ± 1.2
6.6 ± 1.1c,d
tmax(h)
t1/2(h)
AUC0–12(ng h/ml)
AUC0–N(ng h/ml)
1.5 (0.5–2.0)
1.0 (0.5–5.0)
1.3 (0.5–2.0)
2.7 ± 0.7
3.2 ± 0.9
3.7 ± 0.2
24.7 ± 9.6
28.8 ± 14.4
34.5 ± 13.5
26.4 ± 10.5
31.9 ± 17.6
37.9 ± 14.7
5.0 (3.0–7.0)
4.0 (1.5–7.0)b
3.0 (2.0–5.0)b
3.3 ± 1.0
3.2 ± 1.1
3.4 ± 0.4
13.9 ± 5.3
17.4 ± 8.0
44.5 ± 7.4c,d
16.4 ± 6.4
20.1 ± 10.3
52.7 ± 12.5c,d
Data are mean ± SD; tmax data are median (range). Cmax, peak plasma concentration; tmax, time to Cmax; t1/2, elimination half-life; AUC0–12, area under the plasma
concentration–time curve from 0 to 12 h; AUC0–N, area under the plasma concentration–time curve from 0 h to infinity.
a
One of the 12 participants with the c.521TC genotype was excluded from the statistical analysis as an outlier.
b
P < 0.05 vs. participants with the c.521TT genotype.
c
P < 0.001 vs. participants with the c.521TT genotype.
d
P < 0.001 vs. participants with the c.521TC genotype.
that of simvastatin lactone is 419. Simvastatin lactone is
considerably more lipophilic than simvastatin acid, with
experimentally determined octanol/water partition coefficients (logD7.0, at pH 7.0) of 4.40 for simvastatin lactone
and 1.88 for simvastatin acid [35]. The pKa (dissociation
constant) of simvastatin acid is 4.31 and that of
simvastatin lactone is 13.49 (values obtained from the
SciFinder Database, American Chemical Society). Thus,
simvastatin acid is almost completely ionized (charged)
in the human plasma with a pH of about 7.4, whereas the
lactone is almost completely in the un-ionized form. As
simvastatin acid is ionized in the plasma and because it is
only mildly lipophilic, it poorly penetrates the hepatocyte
plasma membrane via passive diffusion and thus requires
active hepatic uptake. On the other hand, the more
lipophilic and neutral simvastatin lactone may diffuse
through the plasma membrane with relative ease.
Similarly to simvastatin acid, the hydrophilic OATP1B1substrate pravastatin (logD7.0 – 0.47 [35], pKa 4.31) is
almost completely ionized at the plasma pH and the
SLCO1B1 c.521C allele is associated with markedly
increased plasma pravastatin concentrations [26–28].
The highest Cmax and AUC of simvastatin acid were seen
in one participant with the SLCO1B1 c.521TC genotype,
who was clearly an outlier among the study participants
(Fig. 2). The diplotype of that participant was *1A/*17.
Two other participants also had this diplotype, but they
had considerably lower simvastatin acid Cmax and AUC
values. It is likely that characteristics other than SLCO1B1
genotype (e.g. genetic variability in carboxylesterase,
CYP3A4, CYP2C8 or UDP-glucuronosyltransferase) also
contributed to the high Cmax and AUC of simvastatin acid
observed in this participant, but further studies beyond
the scope of this investigation are required to determine
the underlying causes. As all participants in the present
study were non-expressers of CYP3A5, however, its
polymorphism cannot explain the finding.
The pattern of differences in the pharmacokinetics of
simvastatin and simvastatin acid between participants with
the c.521CC genotype and those with the c.521TT
genotype is very similar to the changes observed during
concomitant use of simvastatin with gemfibrozil. Gemfibrozil 1200 mg/day raised the AUC of simvastatin acid
about 2.9-fold and that of simvastatin lactone about 1.4fold [33]. Gemfibrozil does not inhibit CYP3A4 [33], but it
and its glucuronide conjugate inhibit CYP2C8 and
OATP1B1 in vitro [36,37]. Considering the similarities in
the effects of gemfibrozil and SLCO1B1 polymorphism on
simvastatin pharmacokinetics, it appears that inhibition of
the OATP1B1-mediated hepatic uptake of simvastatin
acid could be the main mechanism of the pharmacokinetic
interaction between gemfibrozil and simvastatin. Cyclosporine also markedly increases the plasma concentrations
of simvastatin-derived inhibitors of HMG-CoA reductase
[38]. Like gemfibrozil, cyclosporine is an inhibitor of
OATP1B1 [20], but it also inhibits CYP3A4 and the
P-glycoprotein efflux transporter [39,40]. In addition,
cyclosporine inhibits the OATP1B3, OATP2B1 and the
sodium/taurocholate cotransporting polypeptide transporters, which mediate the uptake of rosuvastatin in vitro [41].
No published data exist on the role of these transporters in
the uptake of simvastatin or simvastatin acid. Concomitant
use of simvastatin with gemfibrozil, cyclosporine or a
potent CYP3A4 inhibitor is associated with an increased
risk of myopathy and rhabdomyolysis [5–8].
OATP1B1-mediated uptake of statins into hepatocytes
can be important in terms of enhancing their therapeutic
efficacy and reducing their concentrations in peripheral
blood [42]. Thus, reduced hepatic uptake of the active
simvastatin acid in participants carrying the SLCO1B1
c.521C variant allele may result in both a reduced
cholesterol-lowering efficacy and an increased risk of
systemic adverse effects. In Japanese patients using
pravastatin, atorvastatin or simvastatin, the SLCO1B1
c.521TC genotype was associated with impaired cholesterol-lowering efficacy as compared with the c.521TT
genotype [43]. In addition, the effect of a single 40-mg
dose of pravastatin on hepatic cholesterol synthesis was
reduced in Caucasian carriers of the SLCO1B1*17
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
878 Pharmacogenetics and Genomics 2006, Vol 16 No 12
haplotype containing c.521C [44]. Moreover, the
SLCO1B1*15 haplotype, also containing c.521C, has been
associated with myopathy induced by pravastatin or
atorvastatin in Japanese patients [45]. The SLCO1B1
c.521T > C SNP is common in Caucasian and Asian
populations, with a minor allele frequency of about
15–20% in Caucasians and 10–15% in Asians [32,46].
Therefore, SLCO1B1 polymorphism is likely to play a
major role in interindividual variability in the pharmacokinetics of simvastatin, and possibly in its efficacy and
toxicity, at the population level.
Fig. 2
(a) 25
Cmax (ng/ml)
20
15
10
5
0
Lactone Acid
c.521TT
(b)
Lactone Acid
c.521TC
Lactone Acid
c.521CC
6
In conclusion, genetic polymorphism in SLCO1B1,
encoding the hepatic uptake transporter OATP1B1,
markedly affects the plasma concentrations of simvastatin
acid, the active form of the HMG-CoA reductase
inhibitor simvastatin. Genetic variability in OATP1B1
function can have clinically important consequences for
the balance of risks and benefits of simvastatin treatment.
5
Acknowledgements
We would like to thank Ms Eija Mäkinen-Pulli, Ms Lisbet
Partanen, Ms Kerttu Mårtensson and Mr Jouko Laitila for
skilful technical assistance.
Half - life (h)
4
3
2
References
1
1
2
0
Lactone Acid
c.521TT
Lactone Acid
c.521TC
Lactone Acid
c.521CC
3
(c) 100
4
AUC (ng h/ml)
90
80
5
70
6
60
7
50
8
40
30
9
20
10
0
Lactone Acid
c.521TT
10
Lactone Acid
c.521TC
Lactone Acid
c.521CC
Individual Cmax (a), elimination t1/2 (b) and AUC0–N (c) values of
simvastatin (lactone, solid circles) and simvastatin acid (acid, open
circles) after a single 40-mg oral dose of simvastatin in 32 healthy
Caucasians with different SLCO1B1 c.521T > C genotypes. The data
of an outlier participant with the c.521TC genotype are shown with
solid (simvastatin) and open (simvastatin acid) triangles.
11
12
13
Mauro VF. Clinical pharmacokinetics and practical applications of
simvastatin. Clin Pharmacokinet 1993; 24:195–202.
Scandinavian Simvastatin Survival Study Group. Randomised trial of
cholesterol lowering in 4444 patients with coronary heart disease:
The Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344:
1383–1389.
Vickers S, Duncan CA, Chen IW, Rosegay A, Duggan DE. Metabolic
disposition studies on simvastatin, a cholesterol-lowering prodrug. Drug
Metab Dispos 1990; 18:138–145.
Goldstein JL, Brown MS. Regulation of the mevalonate pathway. Nature
1990; 343:425–430.
Rosenson RS. Current overview of statin-induced myopathy. Am J Med
2004; 116:408–416.
Thompson PD, Clarkson P, Karas RH. Statin-associated myopathy. JAMA
2003; 289:1681–1690.
Williams D, Feely J. Pharmacokinetic–pharmacodynamic drug interactions
with HMG-CoA reductase inhibitors. Clin Pharmacokinet 2002; 41:
343–370.
Graham DJ, Staffa JA, Shatin D, Andrade SE, Schech SD, La Grenade L,
et al. Incidence of hospitalized rhabdomyolysis in patients treated with lipidlowering drugs. JAMA 2004; 292:2585–2590.
Prueksaritanont T, Gorham LM, Ma B, Liu L, Yu X, Zhao JJ, et al. In vitro
metabolism of simvastatin in humans [SBT]: identification of metabolizing
enzymes and effect of the drug on hepatic P450s. Drug Metab Dispos
1997; 25:1191–1199.
Prueksaritanont T, Ma B, Yu N. The human hepatic metabolism of simvastatin
hydroxy acid is mediated primarily by CYP3A, and not CYP2D6. Br J Clin
Pharmacol 2003; 56:120–124.
Prueksaritanont T, Subramanian R, Fang X, Ma B, Qiu Y, Lin JH, et al.
Glucuronidation of statins in animals and humans: a novel mechanism of
statin lactonization. Drug Metab Dispos 2002; 30:505–512.
Neuvonen PJ, Kantola T, Kivistö KT. Simvastatin but not pravastatin is very
susceptible to interaction with the CYP3A4 inhibitor itraconazole. Clin
Pharmacol Ther 1998; 63:332–341.
Kantola T, Kivistö KT, Neuvonen PJ. Erythromycin and verapamil considerably
increase serum simvastatin and simvastatin acid concentrations. Clin
Pharmacol Ther 1998; 64:177–182.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
SLCO1B1 polymorphism and simvastatin Pasanen et al. 879
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Lilja JJ, Kivistö KT, Neuvonen PJ. Grapefruit juice-simvastatin interaction:
effect on serum concentrations of simvastatin, simvastatin acid, and
HMG-CoA reductase inhibitors. Clin Pharmacol Ther 1998; 64:477–483.
Kivistö KT, Niemi M, Schaeffeler E, Pitkälä K, Tilvis R, Fromm MF, et al.
Lipid-lowering response to statins is affected by CYP3A5 polymorphism.
Pharmacogenetics 2004; 14:523–525.
Abe T, Kakyo M, Tokui T, Nakagomi R, Nishio T, Nakai D, et al. Identification
of a novel gene family encoding human liver-specific organic anion
transporter LST-1. J Biol Chem 1999; 274:17159–17163.
Hsiang B, Zhu Y, Wang Z, Wu Y, Sasseville V, Yang WP, et al. A novel human
hepatic organic anion transporting polypeptide (OATP2). Identification of a
liver-specific human organic anion transporting polypeptide and
identification of rat and human hydroxymethylglutaryl-CoA reductase
inhibitor transporters. J Biol Chem 1999; 274:37161–37168.
Hagenbuch B, Meier PJ. Organic anion transporting polypeptides of the
OATP/SLC21 family: phylogenetic classification as OATP/SLCO
superfamily, new nomenclature and molecular/functional properties.
Pflugers Arch 2004; 447:653–665.
Nakai D, Nakagomi R, Furuta Y, Tokui T, Abe T, Ikeda T, et al. Human
liver-specific organic anion transporter, LST-1, mediates uptake of
pravastatin by human hepatocytes. J Pharmacol Exp Ther 2001; 297:
861–867.
Shitara Y, Itoh T, Sato H, Li AP, Sugiyama Y. Inhibition of transportermediated hepatic uptake as a mechanism for drug–drug interaction
between cerivastatin and cyclosporin A. J Pharmacol Exp Ther 2003; 304:
610–616.
Simonson SG, Raza A, Martin PD, Mitchell PD, Jarcho JA, Brown CD, et al.
Rosuvastatin pharmacokinetics in heart transplant recipients administered
an antirejection regimen including cyclosporine. Clin Pharmacol Ther 2004;
76:167–177.
Hirano M, Maeda K, Shitara Y, Sugiyama Y. Contribution of OATP2
(OATP1B1) and OATP8 (OATP1B3) to the hepatic uptake of pitavastatin in
humans. J Pharmacol Exp Ther 2004; 311:139–146.
Kameyama Y, Yamashita K, Kobayashi K, Hosokawa M, Chiba K. Functional
characterization of SLCO1B1 (OATP-C) variants, SLCO1B1*5,
SLCO1B1*15 and SLCO1B1*15 + C1007G, by using transient expression
systems of HeLa and HEK293 cells. Pharmacogenet Genom 2005;
15:513–522.
Kopplow K, Letschert K, König J, Walter B, Keppler D. Human hepatobiliary
transport of organic anions analyzed by quadruple-transfected cells. Mol
Pharmacol 2005; 68:1031–1038.
Tirona RG, Leake BF, Merino G, Kim RB. Polymorphisms in OATP-C:
identification of multiple allelic variants associated with altered transport
activity among European- and African-Americans. J Biol Chem 2001;
276:35669–35675.
Nishizato Y, Ieiri I, Suzuki H, Kimura M, Kawabata K, Hirota T, et al.
Polymorphisms of OATP-C (SLC21A6) and OAT3 (SLC22A8) genes:
consequences for pravastatin pharmacokinetics. Clin Pharmacol Ther
2003; 73:554–565.
Mwinyi J, Johne A, Bauer S, Roots I, Gerloff T. Evidence for inverse effects of
OATP-C (SLC21A6) 5 and 1b haplotypes on pravastatin kinetics. Clin
Pharmacol Ther 2004; 75:415–421.
Niemi M, Schaeffeler E, Lang T, Fromm MF, Neuvonen M, Kyrklund C, et al.
High plasma pravastatin concentrations are associated with single
nucleotide polymorphisms and haplotypes of organic anion transporting
polypeptide-C (OATP-C, SLCO1B1). Pharmacogenetics 2004; 14:
429–440.
Lee E, Ryan S, Birmingham B, Zalikowski J, March R, Ambrose H, et al.
Rosuvastatin pharmacokinetics and pharmacogenetics in white and Asian
subjects residing in the same environment. Clin Pharmacol Ther 2005;
78:330–341.
Chung JY, Cho JY, Yu KS, Kim JR, Oh DS, Jung HR, et al. Effect of
OATP1B1 (SLCO1B1) variant alleles on the pharmacokinetics of
pitavastatin in healthy volunteers. Clin Pharmacol Ther 2005; 78:
342–350.
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
Chen C, Mireles RJ, Campbell SD, Lin J, Mills JB, Xu JJ, et al. Differential
interaction of 3-hydroxy-3-methylglutaryl-coa reductase inhibitors with
ABCB1, ABCC2, and OATP1B1. Drug Metab Dispos 2005; 33:
537–546.
Pasanen MK, Backman JT, Neuvonen PJ, Niemi M. Frequencies of single
nucleotide polymorphisms and haplotypes of organic anion transporting
polypeptide 1B1 SLCO1B1 gene in a Finnish population. Eur J Clin
Pharmacol 2006; 62:463–472.
Backman JT, Kyrklund C, Kivistö KT, Wang JS, Neuvonen PJ. Plasma
concentrations of active simvastatin acid are increased by gemfibrozil.
Clin Pharmacol Ther 2000; 68:122–129.
Wu Y, Zhao J, Henion J, Korfmacher WA, Lapiguera AP, Lin CC.
Microsample determination of lovastatin and its hydroxy acid metabolite in
mouse and rat plasma by liquid chromatography/ion spray tandem mass
spectrometry. J Mass Spectrom 1997; 32:379–387.
Ishigami M, Honda T, Takasaki W, Ikeda T, Komai T, Ito K, et al. A comparison
of the effects of 3-hydroxy-3-methylglutaryl-coenzyme a (HMG-CoA)
reductase inhibitors on the CYP3A4-dependent oxidation of mexazolam in
vitro. Drug Metab Dispos 2001; 29:282–288.
Shitara Y, Hirano M, Sato H, Sugiyama Y. Gemfibrozil and its glucuronide
inhibit the organic anion transporting polypeptide 2 (OATP2/
OATP1B1:SLC21A6)-mediated hepatic uptake and CYP2C8-mediated
metabolism of cerivastatin: analysis of the mechanism of the clinically
relevant drug–drug interaction between cerivastatin and gemfibrozil.
J Pharmacol Exp Ther 2004; 311:228–236.
Yamazaki M, Li B, Louie SW, Pudvah NT, Stocco R, Wong W, et al. Effects of
fibrates on human organic anion-transporting polypeptide 1B1-, multidrug
resistance protein 2- and P-glycoprotein-mediated transport. Xenobiotica
2005; 35:737–753.
Arnadottir M, Eriksson LO, Thysell H, Karkas JD. Plasma concentration
profiles of simvastatin 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase
inhibitory activity in kidney transplant recipients with and without ciclosporin.
Nephron 1993; 65:410–413.
Jacobsen W, Kirchner G, Hallensleben K, Mancinelli L, Deters M,
Hackbarth I, et al. Comparison of cytochrome P-450-dependent metabolism
and drug interactions of the 3-hydroxy-3-methylglutaryl-CoA reductase
inhibitors lovastatin and pravastatin in the liver. Drug Metab Dispos 1999;
27:173–179.
Stapf V, Thalhammer T, Huber-Huber R, Felberbauer F, Gajdzik L, Graf J.
Inhibition of rhodamine 123 secretion by cyclosporin A as a model of
P-glycoprotein mediated transport in liver. Anticancer Res 1994; 14:
581–585.
Ho RH, Tirona RG, Leake BF, Glaeser H, Lee W, Lemke CJ, et al. Drug and
bile acid transporters in rosuvastatin hepatic uptake: function, expression,
and pharmacogenetics. Gastroenterology 2006; 130:1793–1806.
Kim RB. 3-Hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors
(statins) and genetic variability (single nucleotide polymorphisms) in a
hepatic drug uptake transporter: what’s it all about? Clin Pharmacol Ther
2004; 75:381–385.
Tachibana-Iimori R, Tabara Y, Kusuhara H, Kohara K, Kawamoto R, Nakura J,
et al. Effect of genetic polymorphism of OATP-C (SLCO1B1) on lipidlowering response to HMG-CoA reductase inhibitors. Drug Metab
Pharmacokinet 2004; 19:375–380.
Niemi M, Neuvonen PJ, Hofmann U, Backman JT, Schwab M, Lütjohann D,
et al. Acute effects of pravastatin on cholesterol synthesis are associated
with SLCO1B1 (encoding OATP1B1) haplotype *17. Pharmacogenet
Genom 2005; 15:303–309.
Morimoto K, Ueda S, Seki N, Igawa Y, Kameyama Y, Shimizu A, et al.
OATP-C (OATP1B1)*15 is associated with statin-induced myopathy in
hypercholesterolemic patients [Abstract]. Clin Pharmacol Ther 2005;
77:P21.
Nozawa T, Nakajima M, Tamai I, Noda K, Nezu J, Sai Y, et al. Genetic
polymorphisms of human organic anion transporters OATP-C (SLC21A6)
and OATP-B (SLC21A9): allele frequencies in the Japanese population and
functional analysis. J Pharmacol Exp Ther 2002; 302:804–813.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.