There is considerable interest in the therapeutic and adverse outcomes of drug interactions at the blood-brain barrier (BBB) and the blood-cerebrospinal fluid barrier (BCSFB). These include altered efficacy of drugs used in the treatment of CNS disorders, such as AIDS dementia and malignant tumors, and enhanced neurotoxicity of drugs that normally penetrate poorly into the brain. BBB- and BCSFB-mediated interactions are possible because these interfaces are not only passive anatomical barriers, but are also dynamic in that they express a variety of influx and efflux transporters and drug metabolizing enzymes. Based on studies in rodents, it has been widely postulated that efflux transporters play an important role at the human BBB in terms of drug delivery. Furthermore, it is assumed that chemical inhibition of transporters or their genetic ablation in rodents is predictive of the magnitude of interaction to be expected at the human BBB. However, studies in humans challenge this well-established paradigm and claim that such drug interactions will be lesser in magnitude but yet may be clinically significant. This review focuses on current known mechanisms of drug interactions at the blood-brain and blood-CSF barriers and the potential impact of such interactions in humans. We also explore whether such drug interactions can be predicted from preclinical studies. Defining the mechanisms and the impact of drug-drug interactions at the BBB is important for improving efficacy of drugs used in the treatment of CNS disorders while minimizing their toxicity as well as minimizing neurotoxicity of non-CNS drugs.

Animal and histopathological studies of human brain support a role for P-glycoprotein (P-gp) in clearance of cerebral β-amyloid (Aβ) across the blood brain barrier (BBB). We tested the hypothesis that BBB P-gp activity is diminished in Alzheimer’s disease (AD) by accounting for AD-related reduction in regional cerebral blood flow (rCBF). Methods We compared P-gp activity in mild AD patients (n=9) and cognitively normal, age-matched controls (n=9) using positron emission tomography (PET) with a labeled P-gp substrate, [11C]-verapamil, and [15O]-water to measure rCBF. BBB P-gp activity was expressed as the [11C]-verapamil radioactivity extraction ratio (ER={[11C]-verapamil brain distributional clearance, K1}/rCBF). Results Compared to controls, BBB P-gp activity was significantly lower in the parietotemporal, frontal, posterior cingulate cortices and hippocampus of mild AD subjects. Conclusion BBB P-gp activity in brain regions affected by AD is reduced and is independent of rCBF. This study improves on prior work by eliminating the confounding effect that reduced rCBF has on assessment of BBB P-gp activity and suggests that impaired P-gp activity may contribute to cerebral Aβ accumulation in AD. P-gp induction/activation to increase cerebral Aβ clearance could constitute a novel preventive or therapeutic strategy for AD.

To predict the magnitude of P-glycoprotein (P-gp)-based drug interactions at the human blood-brain barrier (BBB), rodent studies are routinely conducted where P-gp is chemically inhibited. For such studies to be predictive of interactions at the human BBB, the plasma concentration of the P-gp inhibitor must be comparable with that observed in the clinic. Therefore, we determined the in vivo EC 50 of P-gp inhibition at the rat BBB using verapamil as a model P-gp substrate and cyclosporine A (CsA) as the model P-gp inhibitor. Under isoflurane anesthesia, male Sprague-Dawley rats were administered i.v. CsA to achieve pseudo steady-state CsA blood concentrations ranging from 0 to ϳ12 M. Then, an i.v. tracer dose of [ 3 H]verapamil was administered, and 20 min after verapamil administration, the animals were sacrificed for determination of blood, plasma, and brain 3 H radioactivity by scintillation counting. The percentage increase in the brain/blood 3 H radioactivity (relative to 0 M CsA) was described by the Hill equation with E max , 1290%; EC 50 , 7.2 M; and ␥, 3.8. Previously, using [11 C]verapamil, we have shown that the human brain/blood 11 C radioactivity was increased by 79% at 2.8 M CsA blood concentration. At an equivalent CsA blood concentration, the rat brain/blood 3 H radioactivity was increased by a remarkably similar extent of 75%. This is the first time that an in vivo CsA EC 50 of P-gp inhibition at the rat BBB has been determined and the magnitude of such inhibition was compared between the rat and the human BBB at the same blood CsA concentration.

ABSTRACT:In vitro inhibition of P-glycoprotein (P-gp) expressed in cells is routinely used to predict the potential of in vivo P-gp drug interactions at the human blood-brain barrier (BBB). The accuracy of such predictions has not been confirmed because methods to quantify in vivo P-gp drug interactions at the human BBB have not been available. With the development of a noninvasive positron emission topography (PET) imaging method by our laboratory to determine P-gp-based drug interactions at the human BBB, an in vitro-in vivo comparison is now possible. Therefore, we developed a high throughput cell-based assay to determine the potential of putative P-gp inhibitors [including cyclosporine A (CsA)] to inhibit (EC 50 ) the efflux of verapamil-bodipy, a model P-gp substrate. LLCPK1-MDR1 cells, expressing recombinant human P-gp, or control cells lacking P-gp (LLCPK1) were used in our assay. Using this assay, quinine, quinidine, CsA, and amprenavir were predicted to be the most potent P-gp inhibitors in vivo at their respective therapeutic maximal unbound plasma concentrations. The in vitro EC 50 of CsA (0.6 M) for P-gp inhibition was virtually the same as our previously determined in vivo unbound EC 50 at the rat BBB (0.5 M). Moreover, at 2.8 M CsA (total blood concentration), our in vitro data predicted an increase of 129% in [11 C]verapamil distribution into the human brain, a value similar to that observed by us (79%) using PET. These data suggest that our high throughput cell assay has the potential to accurately predict P-gp drug interactions at the human BBB.The in vivo importance of P-glycoprotein (P-gp) at the BBB has been well demonstrated by studies in mdr1a/b (Ϫ/Ϫ) mice. For example, compared with the wild-type mouse, in the mdr1a/b (Ϫ/Ϫ) mice, the brain/plasma concentration ratio (or the brain uptake) of the anti-human immunodeficiency virus protease inhibitors is increased 7-to 36-fold and anti-cancer taxanes, paclitaxel, or docetaxel are increased 6-to 28-fold, whereas that of verapamil is increased 8.5-fold (Endres et al., 2006). Similar data have been obtained in mice and rats where P-gp has been chemically ablated with selective inhibitors of P-gp such as PSC833, GF120918, and LY335979 (Lin and Yamazaki, 2003;Endres et al., 2006). For example, the brain/plasma ratio of verapamil is increased 24.1-fold when the rat is pretreated with cyclosporine A (CsA) (Hendrikse and Vaalburg, 2002). Based on these data and others, it has been widely postulated that P-gp plays a vital role in limiting drug distribution at the human BBB and that P-gp-based drug interactions will result in a profound increase in brain concentrations of the affected drugs and, therefore, their CNS efficacy or toxicity.Although rodent studies make a compelling case for the importance of P-gp at the BBB in the CNS distribution of drugs, their ability to predict the magnitude of P-gp-based drug interactions at the human BBB has not been investigated. Due to safety and ethical reasons, it has not been possible to measure in vivo human BB...

Permeability-glycoprotein (P-glycoprotein, P-gp), an efflux transporter at the human blood-brain barrier (BBB), is a significant obstacle to central nervous system (CNS) delivery of P-gp substrate drugs. Using positron emission tomography imaging, we investigated P-gp modulation at the human BBB by an approved P-gp inhibitor, quinidine, or the P-gp inducer, rifampin. Cerebral blood flow (CBF) and BBB P-gp activity were respectively measured by administration of (15)O-water followed by (11)C-verapamil. In a crossover design, healthy volunteers received quinidine and 11-29 days of rifampin treatment during different study periods. CBF and P-gp activity was measured in the absence (control; prior to quinidine treatment) and presence of P-gp modulation. At clinically relevant quinidine plasma concentrations, P-gp inhibition resulted in a 60% increase in (11)C-radioactivity distribution across the human BBB as measured by the brain extraction ratio (ER) of (11)C-radioactivity. Furthermore, the magnitude of BBB P-gp inhibition by quinidine was successfully predicted by a combination of in vitro and macaque data, but not by rat data. Although our findings demonstrated that quinidine did not completely inhibit P-gp at the human BBB, it has the potential to produce clinically significant CNS drug interactions with P-gp substrate drugs that exhibit a narrow therapeutic window and are significantly excluded from the brain by P-gp. Rifampin treatment induced systemic CYP3A metabolism of (11)C-verapamil; however, it reduced the ER by 6%. Therefore, we conclude that rifampin, at its usual clinical dose, cannot be used to induce P-gp at the human BBB to a clinically meaningful extent and is unlikely to cause inadvertent BBB-inductive drug interactions.