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Effect of High-Dose Metronidazole on Pharmacokinetics of Oral Budesonide and Vice Versa: A

Double Drug Interaction Study
Karin Dilger, Richard Fux, Daniel Röck, Klaus Mörike and Christoph H. Gleiter
J. Clin. Pharmacol. 2007; 47; 1532
DOI: 10.1177/0091270007308617

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Effect of High-Dose Metronidazole on
Pharmacokinetics of Oral Budesonide and Vice
Versa: A Double Drug Interaction Study
Karin Dilger, MD, Richard Fux, MD, Daniel Röck, Klaus Mörike, MD,
and Christoph H. Gleiter, MD, FCP
Recent case reports suggest that addition of high-dose
metronidazole might be associated with elevated plasma
concentrations of substrates of cytochrome P450 (CYP) 3A.
Because patients with fistulizing Crohn’s disease benefit by
using high doses of metronidazole for prolonged periods, this
study’s primary aim was to evaluate the effect of high-dose
metronidazole on the pharmacokinetics of oral budesonide,
a sensitive substrate of CYP3A commonly prescribed in acute
inflammatory bowel disease. Twelve healthy adults received
1.5 g metronidazole per day over 1 week. The CYP3A-depen-
dent metabolic profile of an oral dose of budesonide (3 mg)
and that of endogenous cortisol were compared intraindivid-
ually before and after administration of metronidazole. There
was neither a significant effect of high-dose metronidazole on
the area under the plasma concentration-time curve (AUC) of
D rug interactions represent a serious problem in
clinical practice. With an increased under-
standing of drug-metabolizing enzymes and their
roles in the biotransformation of specific substances,
it is possible to apply a more mechanistic approach
to assessing drug interactions in vivo.1 Cytochrome
From Dr. Falk Pharma GmbH, Freiburg, Germany (Dr Dilger); Department
of Clinical Pharmacology, Institute of Pharmacology and Toxicology, University
Hospital Tübingen, Tübingen, Germany (Dr Fux, Mr Röck, Dr Mörike,
Dr Gleiter); and Coordination Centre for Clinical Trials at University
Hospitals Tübingen and Ulm, Tübingen, Germany (Dr Gleiter). Dr Dilger
and Dr Fux contributed equally to this work. Submitted for publication
July 3, 2007; revised version accepted August 21, 2007. Address for
correspondence: Christoph H. Gleiter, Department of Clinical Pharma-
cology, Institute of Pharmacology and Toxicology, University Hospital
Tübingen, Otfried-Müller-Str. 45, D-72076 Tübingen, Germany; e-mail:
christoph.gleiter@med.uni-tuebingen.de.
DOI: 10.1177/0091270007308617
1532 • J Clin Pharmacol 2007;47:1532-1539
DRUG INTERACTIONS
budesonide (90% confidence interval, 79%-115%) nor on the
AUC ratios of 6β-hydroxybudesonide/budesonide and 16α-
hydroxyprednisolone/budesonide. In parallel, metronidazole
did not significantly alter formation of 6β-hydroxycortisol.
Vice versa, budesonide did not affect the AUC of metronida-
zole (90% confidence interval, 91%-100%). The authors
conclude that in contrast to concomitant intake of other imi-
dazoles such as ketoconazole, concomitant intake of metron-
idazole may not lead to serious safety concerns due to
elevated systemic concentrations of the glucocorticoid
budesonide.
Keywords: Budesonide; cortisol; CYP3A; metronidazole
Journal of Clinical Pharmacology, 2007;47:1532-1539
© 2007 the American College of Clinical Pharmacology
P450 (CYP) 3A is the most abundant cytochrome
subfamily in man, and it contributes to metabolism
of approximately half the drugs in use today and of
various endogenous compounds.2,3 Clinical evalua-
tion of the inhibition of CYP3A is of special interest
because this type of drug interaction may lead to
serious safety concerns.4
Metronidazole is an N-substituted imidazole
antibiotic that is active against a wide variety of
anaerobic protozoal parasites and anaerobic bacteria.
In contrast to other indications, in Crohn’s disease,
high doses of metronidazole (20 mg/kg per day) are
used for prolonged periods up to several months.5
The suspected role of bacteria in the pathogenesis of
Crohn’s disease provides the rationale for using
adjunctive antibiotics. Imidazole derivatives struc-
turally related to metronidazole such as ketoconazole
or itraconazole are strong inhibitors of CYP3A, caus-
ing a more than 5-fold increase in the area under the
 EFFECT OF HIGH-DOSE METRONIDAZOLE ON ORAL BUDESONIDE
plasma concentration-time curve (AUC) of CYP3A
substrates.6 Metronidazole may inhibit CYP3A
according to in vitro data,7 but it has been shown
that low-dose metronidazole (400 mg twice daily)
did not affect the pharmacokinetics of the CYP3A
substrate midazolam.8 However, 3 recent case
reports describing (1) the elevation of tacrolimus
trough concentrations (dual substrate of CYP3A and
P-glycoprotein [P-gp]) by addition of 2 g metronida-
zole per day, (2) the occurrence of Torsades de
Pointes due to coadministration of 1.5 g metronida-
zole per day and amiodarone (substrate of CYP3A),
and (3) an indication for an unexpected drug inter-
action between metronidazole (25 mg/kg per day)
and oral budesonide in a patient with Crohn’s dis-
ease substantiated our decision to test the effect of
high-dose metronidazole on the pharmacokinetics of
oral budesonide.9-11
In a recent guidance document on drug interaction
studies by the US Food and Drug Administration
defining the best practices, budesonide is given as
sensitive substrate of CYP3A.12 The drug is a newer
synthetic glucocorticoid with high glucocorticoid
receptor binding affinity and a low rate of systemic
side effects because of low systemic bioavailabil-
ity.13 Absolute bioavailability of oral budesonide is
10% due to extensive first-pass metabolism in gut
and liver by CYP3A enzymes.14 The main metabo-
lites formed via CYP3A are 6β-hydroxybudesonide
and 16α-hydroxyprednisolone.15 Moreover, budes-
onide is a substrate of the intestinal drug efflux pump,
P-gp.16 Oral budesonide is approved for the treat-
ment of mild to moderate exacerbations of Crohn’s
disease, the incidence of which has been shown to
be increasing rapidly in Western countries.17,18
For safety reasons, it must be clarified if patients
with Crohn’s disease who are using the standard
dosage of oral budesonide are at an increased risk of
Cushingoid symptoms and other steroid-related side
effects during treatment with metronidazole because
of elevated systemic budesonide concentrations
resulting from inhibition of biotransformation via
CYP3A. Therefore, the primary aim of the study was
to investigate the impact of 1.5 g metronidazole per
day, given over 1 week, on the CYP3A-dependent
metabolic profile of budesonide and that of endoge-
nous cortisol. CYP3A catalyzes the transformation of
cortisol to 6β-hydroxycortisol.19 The secondary aim
was to study vice versa a possible effect of budes-
onide on the disposition of metronidazole due to a
report on a significant reduction of metronidazole
plasma concentrations in 6 patients with Crohn’s
DRUG INTERACTIONS
disease by coadministration of the older synthetic
glucocorticoid, prednisone.20
METHODS
Subjects
Twelve healthy male Caucasians (30.3 ± 5.6 years,
74.9 ± 9.8 kg, 23.2 ± 2.6 kg/m2; mean ± SD) were
enrolled in the drug interaction study during May
2006. All subjects were nonsmokers. Intake of any
medication within the 2 weeks before or during the
conduct of the trial precluded participation. Further
exclusion criteria were administration of any gluco-
corticoid within 6 weeks before the first study day,
use of drugs during the 4 weeks before the first study
day that might influence CYP3A activity,21 and
intake of grapefruit within 1 week before the first
study day or during the trial.
Study Design
The investigation was conducted as a fixed-order
study. In the morning on study days 1 and 9, a sin-
gle oral dose of 3 mg budesonide was administered.
On study days 2 to 8, each subject received 1.5 g
metronidazole per day (divided into a morning and
an evening dose). On study day 9, last metronidazole
(750 mg) was given simultaneously with oral budes-
onide. To ensure compliance, each subject had to
report to the study site for each drug intake (mouth
check). Subjects were hospitalized the evening
before study days 1, 8, and 9. After an overnight fast,
a standardized lunch was served not until 4 hours
after ingestion of the study drug(s), and intake of fluid
was standardized over 8 hours. Pharmacokinetic
profiling of budesonide was performed identically
on study days 1 and 9 by determination of budes-
onide and the 2 CYP3A-dependent metabolites (6β-
hydroxybudesonide, 16α-hydroxyprednisolone) in
plasma before and during 24 hours after drug intake.
In detail, blood samples were collected just before
and 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 7, 8, 10, 12, and
24 hours after drug administration. Pharmacokinetic
profiling of metronidazole was performed on study
days 8 and 9 by measuring metronidazole in plasma;
blood samples were collected just before and 0.5, 1,
1.5, 2, 3, 4, 6, 8, and 12 hours after drug administra-
tion. To prove that the dosing strategy was adequate
to achieve steady state during the interaction, blood
samples for trough concentrations of metronidazole
1533
 DILGER ET AL
were collected before each morning dosing on study
days 6 to 8. On study days 1 and 9, urine was col-
lected for 12 hours after dosing to determine urinary
excretion of cortisol and 6β-hydroxycortisol. Plasma
and urine were stored at –20°C until batch analysis.
Analytical Methods
Concentrations of budesonide, 6β-hydroxybudesonide,
and 16α-hydroxyprednisolone in plasma were deter-
mined by validated liquid chromatography tandem
mass spectrometry as described previously.22 The
mass-to-charge transition (m/z) was monitored at
489.2 to 339.2 for budesonide, 505.0 to 373.1 for 6β-
hydroxybudesonide, 374.9 to 327.1 for 16α-hydrox-
yprednisolone, and 492.8 to 375.2 for the internal
standard (flunisolide). The lower limits of quantifi-
cation in plasma were 0.1 ng/mL for budesonide and
6β-hydroxybudesonide and 0.5 ng/mL for 16α-
hydroxyprednisolone. Between-day and within-day
coefficients of variation of quality controls were less
than 15%. Concentrations of cortisol and 6β-hydrox-
ycortisol in urine were determined by validated liq-
uid chromatography tandem mass spectrometry. The
mass-to-charge transition (m/z) was monitored at
421.1 to 331.2 for cortisol, 437.1 to 347.0 for 6β-
hydroxycortisol, and 451.2 to 361.1 for the internal
standard (dexamethasone). The lower limit of quan-
tification was 1 ng/mL. Between-day and within-day
coefficients of variation of quality controls were less
than 10%. Concentrations of metronidazole in
plasma were determined by standard high-perfor-
mance liquid chromatography.23 The lower limit of
quantification was 0.03 μg/mL. Between-day and
within-day coefficients of variation of quality con-
trols were less than 7%.
Pharmacokinetic and
Pharmacodynamic Analyses
Standard model-independent methods were used to
determine the pharmacokinetic parameters of interest
(Kinetica Version 4.0, Thermo Electron Corporation,
Philadelphia, Pennsylvania). Peak plasma concentra-
tion (Cmax) and time of Cmax (tmax) were taken directly
from the plasma concentration-time curves. Areas
under the plasma concentration-time curves covering
different intervals (eg, AUC0-24 h) were determined by
a combination of linear and logarithmic trapezoidal
methods with extrapolation to infinity (AUC0-∞).
Terminal elimination half-life (t1/2) was calculated from
the final slope of the log-linear concentration-time
curve by least squares linear regression. Apparent
1534 • J Clin Pharmacol 2007;47:1532-1539
oral clearance (CL/f = dose/AUC0-∞) and apparent
volume of distribution (Vd/f = dose/[AUC0-∞⋅λ]) were
normalized for body weight. Peak trough fluctuation
(PTF) of metronidazole plasma concentrations at
steady state was derived from the equation PTF =
100⋅(Css,max – Css,min)/Css,av with Css,av = AUCss,0-12 h/12.
Ratios of metabolite formation (AUCMet/ AUCBudesonide,
where Met is the CYP3A-dependent metabolite), such
as AUC0-24 h of 6β-hydroxybudesonide to AUC0-24 h of
budesonide, were used as indices of CYP3A activity.
In addition, possible induction or inhibition of
CYP3A enzymes by metronidazole was evaluated by
measuring the cumulative amount of cortisol and
6β-hydroxycortisol excreted into the urine during the
12-hour collection period (Ae0-12 h); metabolic ratios
(Ae6β-OH-cortisol/Aecortisol) were calculated in each subject.
Statistical Analysis
The study had a 94% power to detect a 20% differ-
ence in the plasma AUC of budesonide between
study day 1 and study day 9 with a P value of less
than .05. Sample size calculation was based on the
coefficient of variation of the budesonide AUC in a
previous study.22 Statistical analysis was performed
by use of the software package GraphPad Instat
(Version 3.05, GraphPad Software, Inc., San Diego,
California). Wilcoxon matched pairs test was per-
formed to compare pharmacokinetic/pharmacody-
namic parameters between 2 different study days
(eg, day 1 vs day 9). Two-sided P < .05 was regarded
as statistically significant. According to the guide-
lines by the US Food and Drug Administration and
the European Medicines Agency, the ratio of means
with confidence intervals (CIs) of AUC and Cmax are
the characteristics to determine equivalence for orally
administered drugs; parametric testing using analy-
sis of variance (ANOVA) on log-transformed data is
the rule. Therefore, 90% CIs of the log-transformed
parameters AUC0-24 h [AUCss,0-12 h] and Cmax [Css,max] of
budesonide [metronidazole] before and during
metronidazole [budesonide] administration were
derived from the residual variance in multifactor
ANOVA. The 90% CIs were based on the ratios of
the population means (during/before comedication).
Ethics
The study protocol was approved by the ethics com-
mittee of the University Hospital Tübingen. The
study was conducted in accordance with the ethical
guidelines of the Declaration of Helsinki and the Inter-
national Conference on Harmonization guidelines
 EFFECT OF HIGH-DOSE METRONIDAZOLE ON ORAL BUDESONIDE

for good clinical practice. Written informed consent Table I Pharmacokinetic Parameters of
was obtained from each participant. The project is Budesonide and 2 CYP3A-Dependent Metabolites
registered in the public trials registry sponsored by the
US National Library of Medicine (www.clinicaltrials Baseline With Metronidazole
.gov, #NCT00338910). Budesonide
Cmax, ng/mL 1.00 ± 0.35 1.04 ± 0.40
RESULTS tmax, h 4.5 (4.1−6.2) 4.5 (3.9−4.8)
tlag, h 3.0 (2.8−3.8) 2.8 (2.0−3.4)
All subjects completed the study according to the AUC0−∞, h⋅ng/mL 4.88 ± 2.04 4.77 ± 2.11
protocol with excellent compliance. The study t1/2, h 2.6 (2.1−5.1) 3.6 (2.6−6.0)
drugs were well tolerated. There was no serious CL/f, L/min/kg 0.17 ± 0.08 0.18 ± 0.09
Vd/f, L/kg 43.8 ± 15.2 60.6 ± 38.1
adverse drug reaction. Metronidazole trough con-
6β-OH-Budesonide
centrations in plasma did not differ significantly
Cmax, ng/mL 1.36 ± 0.56 1.36 ± 0.45
between study days 6 to 8 (ANOVA), which means tmax, h 4.8 (4.1−6.9) 4.5 (4.0−5.0)
that steady state was achieved on study day 8. tlag, h 3.0 (2.1−3.8) 2.8 (2.0−3.3)
AUC0−∞, h⋅ng/mL 9.11 ± 3.64 8.52 ± 2.64
Effect of Metronidazole t1/2, h 4.8 (3.5−6.0) 3.8 (3.4−7.5)
on Budesonide and Cortisol 16α-OH-Prednisolone
Cmax, ng/mL 8.94 ± 3.76 9.92 ± 2.70
Pharmacokinetic parameters of budesonide and both tmax, h 5.3 (4.5−6.8) 4.5 (4.0−5.1)
tlag, h 2.8 (1.9−3.6) 2.5 (1.8−3.1)
CYP3A-dependent metabolites (mean ± SD or median
AUC0−∞, h⋅ng/mL 33.27 ± 6.29 33.69 ± 6.19
with 95% CI) are given in Table I for comparison of t1/2, h 1.6 (1.3−2.7) 2.0 (1.6−2.5)
baseline (study day 1) with the effect of high-dose
metronidazole (study day 9). Wilcoxon testing did not Cmax, peak plasma concentration; tmax, time of peak plasma concentra-
tion; tlag, lag time; AUC0−∞, area under the plasma concentration-time
reveal a significant difference between study day 1 curve extrapolated to infinity; t1/2, terminal elimination half-life; CL/f,
and study day 9 in any of the parameters displayed apparent oral clearance; Vd/f, apparent volume of distribution.
(eg, AUC0-∞ of budesonide: 4.88 ± 2.04 h⋅ng/mL vs 4.77
± 2.11 h⋅ng/mL). Mean plasma concentration-time
1.5
curves of budesonide, 6β-hydroxybudesonide, and
Day 1
Plasma Budesonide (ng/mL)

16α-hydroxyprednisolone are shown in Figures 1 to 3.

Administration of 1.5 g metronidazole per day over 1 Day 9
1.0
week did not affect the metabolism of budesonide via
CYP3A: neither formation of 6β-hydroxybudesonide
nor formation of 16α-hydroxyprednisolone was signif-
0.5
icantly reduced by metronidazole (AUCMet/AUCBud:
2.1 ± 0.8 vs 2.0 ± 0.7, 6β-hydroxybudesonide; 8.3 ± 3.6
vs 9.1 ± 4.7, 16α-hydroxyprednisolone; day 1 vs day 9;
Figure 4). The 90% CI of AUC ratios of budesonide
0 2 4 6 8 10 12 14 16 18 20 22 24
during metronidazole administration relative to base-
Time (h)
line was 0.79 to 1.15, with the ratio of means being
0.95; the 90% CI of Cmax was 0.76 to 1.39, with the
Figure 1. Plasma budesonide concentration-time curves in 12
ratio of means being 1.03. In parallel to the metabo- subjects following a single oral dose of 3 mg budesonide on study
lite kinetics of budesonide, CYP3A-dependent corti- day 1 before (solid circle) and on study day 9 after (open circle)
sol biotransformation was not significantly altered 7 days of twice-daily dosing of metronidazole (total 1.5 g/day)
with the last morning dose of metronidazole (750 mg) on study
by intake of high-dose metronidazole over 1 week day 9. Data are presented as mean and SD.
(Ae6β-OH-cortisol/Aecortisol: 7.6 ± 4.3 vs 6.7 ± 3.4, day 1 vs
day 9; Figure 5).
day 8) with the effect of a single dose of budesonide
Effect of Budesonide on Metronidazole (study day 9). Mean plasma concentration-time curves
of metronidazole are shown in Figure 6. Wilcoxon
Pharmacokinetic parameters of metronidazole (mean ± testing did not reveal a significant difference between
SD or median with 95% CI) during steady-state dosing study day 8 and study day 9 in peak concentra-
are given in Table II for comparison of baseline (study tions (Css,max), tss,max, and PTF. AUCss,0-12 h and trough

DRUG INTERACTIONS 1535

 DILGER ET AL

2.0 Day 1 Day 9

Plasma 6β-OH-Budesonide (ng/mL)

15
Day 1
1.5
Day 9

AUCMet/AUCBudesonide
10
1.0

0.5
5

0
0 2 4 6 8 10 12 14 16 18 20 22 24
0

Time (h) 6β-OH-Budesonide 16α-OH-Prednisolone

Figure 2. Plasma 6β-hydroxybudesonide concentration-time Figure 4. Ratios of CYP3A-dependent metabolite formation

curves in 12 subjects following a single oral dose of 3 mg budes-
onide on study day 1 before (solid circle) and on study day 9 after
(open circle) 7 days of twice-daily dosing of metronidazole (total
1.5 g/day) with the last morning dose of metronidazole (750 mg)
on study day 9. Data are presented as mean and SD.
Plasma 16α-OH-Prednisolone (ng/mL)
(AUCMet/AUCBudesonide where Met is the metabolite) following a sin-
gle oral dose of 3 mg budesonide on study day 1 before (black)
and on study day 9 after (white) 7 days of twice-daily dosing of
metronidazole (total 1.5 g/day) with the last morning dose of
metronidazole (750 mg) on study day 9. Data are presented as
mean and SD.

12.0 20

Day 1
10.0
Day 9 15
8.0
AeMet/AeCortisol

6.0
10
4.0

2.0 5

0
0 2 4 6 8 10 12 14 16 18 20 22 24 0
Time (h) Day 1 Day 9

Figure 3. Plasma 16α-hydroxyprednisolone concentration-time Figure 5. CYP3A-dependent cortisol biotransformation (AeMet/

curves in 12 subjects following a single oral dose of 3 mg budes-
onide on study day 1 before (solid circle) and on study day 9 after
(open circle) 7 days of twice-daily dosing of metronidazole (total
1.5 g/day) with the last morning dose of metronidazole (750 mg)
on study day 9. Data are presented as mean and SD.
AeCortisol where AeMet is urinary excretion of 6β-hydroxycortisol
during 12 hours and AeCortisol is urinary excretion of cortisol dur-
ing 12 hours) on study day 1 before and on study day 9 after 7
days of twice-daily dosing of metronidazole (total 1.5 g/day) with
the last morning dose of metronidazole (750 mg) on study day 9.

concentrations (Css,min) of metronidazole were signif- We observed no increase in the plasma AUC of
icantly lower on study day 9 than on study day 8 budesonide (point estimate 0.95) upon coadminis-
(P < .05). The 90% CIs of both AUC and the Cmax ratio tration with metronidazole. Daily intake of 1.5 g
of metronidazole during budesonide administration metronidazole over 1 week did not significantly
relative to baseline were narrow (AUC: 0.91-1.00, affect the biotransformation of oral budesonide via
Cmax: 0.90-1.08), with the ratios of means being near CYP3A as shown by extensive analysis of metabolite
to 1.00 (AUC: 0.96, Cmax: 0.99). kinetics in plasma; AUC ratios of 6β-hydroxybudes-
onide/budesonide and 16α-hydroxyprednisolone/
DISCUSSION budesonide have been validated previously as a marker
of CYP3A activity using the prototype inducer
This human study shows that high-dose metronidazole rifampicin.24 Likewise, we found no significant
does not affect the pharmacokinetics of oral budesonide. effect by high-dose metronidazole on the formation

1536 • J Clin Pharmacol 2007;47:1532-1539

 EFFECT OF HIGH-DOSE METRONIDAZOLE ON ORAL BUDESONIDE

Table II Pharmacokinetic Parameters of treatment period longer than 3 days for our system-
Metronidazole atic evaluation. However, no such drug interaction
was found.
Baseline With Budesonide Interestingly, there are case reports describing an
Css,max, μg/mL 27.6 ± 5.1 26.9 ± 2.9 increase in plasma concentrations of dual substrates
tss,max, h 0.5 (0.5−0.8) 0.5 (0.5−0.8) of CYP3A and P-gp with a narrow therapeutic range
Css,min, μg/mL 11.4 ± 2.5 10.6 ± 2.1* (tacrolimus, cyclosporine, carbamazepine, quini-
AUCss,0-12 h, h⋅μg/mL 193.6 ± 28.0 184.6 ± 23.6* dine) by coadministration of metronidazole9,26-30; for
PTF, % 101.4 ± 22.1 107.9 ± 23.3 example, 2 case reports document marked elevation
in tacrolimus concentrations with the addition of
Css,max, peak plasma concentration at steady state; tss,max, time of peak
plasma concentration at steady state; Css,min, trough plasma concentra- metronidazole,9,26 and 3 case reports describe a
tion at steady state; AUCss,0-12 h, area under the plasma concentration- harmful increase in cyclosporine concentrations in
time curve at steady state during the dosing interval of 12 hours; PTF, patients due to concurrent metronidazole.26,29,30
peak trough fluctuation at steady state.
*P < .05 vs baseline (Wilcoxon test). Some of the authors suggested that metronidazole
should be added to the list of CYP inhibitors that can
produce clinically important drug interactions.
The publication on the concurrent use of amio-
35 darone and metronidazole highlighted a serious phar-
macodynamic effect on the conduction system of the
Plasma Metronidazole (µg/mL)

30
25
20
15
10
5 tion of budesonide, which was no more observed 1
0
0 2 4 6 8 10 12 14
Time (h)
Figure 6. Plasma metronidazole concentration-time curves in
12 subjects during steady-state (twice-daily dosing of metronida-
zole, total 1.5 g/day) following an oral morning dose of 750 mg
metronidazole on study day 8 without (solid circle) and on study
day 9 together with (open circle) a single oral dose of 3 mg budes-
onide. Data are presented as mean and SD.
of 6β-hydroxycortisol, which is an older validated
test for evaluating induction and inhibition of
CYP3A enzymes.19,25
A previous clinical trial in 10 healthy volunteers
examining the CYP3A-altering properties of low-
dose metronidazole (400 mg twice daily during 3
days) found no effect (midazolam plasma AUC ratio
0.93).8 As that study evaluated only the effect of low-
dose metronidazole during a short course of treatment,
that result does not exclude the possibility of a sig-
nificant effect of metronidazole on CYP3A activity at
a higher dosage or a longer duration of treatment as
suggested in the newer case reports. Because testing
for a possible drug interaction should maximize the
possibility of finding an interaction, we used the
maximum approved dose of metronidazole with a
Day 8
heart with positive dechallenge but did not provide
Day 9 information on drug concentrations in plasma for a
precise interpretation.10 A study patient who had
taken metronidazole (1.2 g per day during 12 days)
until the evening before the first administration of
oral budesonide showed remarkably delayed absorp-
week later following withdrawal of metronidazole.
16 18 20 22 24 Rechallenge was impossible in that subject because of
resection of the ileum a short time later. The results of
our study do not confirm the previous observation: lag
time of budesonide was not prolonged by metron-
idazole. Altered intraluminal pH, delayed gastric
emptying, or intestinal transit might explain delayed
absorption of the enteric-coated budesonide prepa-
ration in an isolated case.11
We started our trial knowing that there is no
simple relationship between in vitro inhibition
potency of a substance and magnitude of drug inter-
action in the clinical setting. Some CYP3A
inhibitors that did not demonstrate high in vitro
potency had been shown to cause drug interactions
of more than a 2-fold increase in AUC. These
include CYP3A inhibitors causing mechanism-based
irreversible inactivation (eg, clarithromycin, dilti-
azem).31 Unlike other human CYP enzymes, CYP3A
offers the complicating factor that there appear to be
3 different substrate-binding types.32 In addition, the
magnitude of an interaction on a CYP3A probe will
depend on the amount of intestinal versus hepatic
extraction with those drugs that have a greater intesti-
nal extraction with larger interactions.31 Thus, very
low bioavailability of oral budesonide at baseline might
have increased several-fold in the face of CYP3A

DRUG INTERACTIONS 1537

 DILGER ET AL
inhibition by high-dose metronidazole. At least a
doubling of systemic exposure in the presence of an
inhibitor was agreed to be reasonable for labeling
action.1
Taking our data on CYP3A-dependent metabolite
formation of budesonide and CYP3A-dependent cor-
tisol biotransformation together, we assume that
patients with Crohn’s disease who are using the stan-
dard dosage of budesonide are not at an increased risk
of Cushingoid symptoms or other steroid-related side
effects during intake of high-dose metronidazole. This
negative finding is important for clinicians and
patients because antibiotics, metronidazole and
ciprofloxacin, are the first line of medical therapy for
fistulizing Crohn’s disease.33 Moreover, metronida-
zole can also help to control colonic Crohn’s disease
or postoperative recurrence.34-36
One might then speculate about the discrepancy
between case reports and results from clinical trials.
Other investigators suggested that metronidazole
may be a modulator or substrate of P-gp.8 To the best
of our knowledge, there are no data available on this
interesting issue. It is unknown if the effect of
metronidazole on tacrolimus or the other dual sub-
strates cited above is due to a change in activity of
CYP3A, P-gp, or both. However, if metronidazole
had significantly affected the drug efflux pump, we
would have observed altered absorption or elimina-
tion characteristics of oral budesonide, which is also
a dual substrate of P-gp and CYP3A. Thus, further
studies are required for identifying whether metron-
idazole is a P-gp substrate and/or inhibitor.
In contrast to prednisone, budesonide did not aug-
ment the elimination of metronidazole. Whereas oral
clearance of metronidazole was increased by 40% by
concurrent prednisone, it was increased by 5% by
concurrent budesonide. Trough concentrations but
not peak concentrations of metronidazole decreased
by approximately 7% due to concurrent budesonide.
Because metronidazole is a drug without a narrow
therapeutic range, this alteration in clearance was
assessed to be clinically irrelevant. A correlation
between serum concentration and effect as known in
aminoglycosides does not exist for metronidazole.37
Metronidazole undergoes hepatic metabolism, form-
ing 5 metabolites with markedly reduced or negligible
antimicrobial activity; the involved drug-metaboliz-
ing enzymes are not known.38
In summary, our double drug interaction study
with metronidazole and budesonide does not sup-
port generalizing conclusions from single case
reports where addition of high-dose metronidazole has
been associated with elevated plasma concentrations
1538 • J Clin Pharmacol 2007;47:1532-1539
of substrates of CYP3A. High-dose metronidazole does
not affect the pharmacokinetics of oral budesonide
or vice versa.
Financial disclosure: This work was supported by Dr. Falk
Pharma GmbH, Freiburg, Germany. Dr Dilger is head of drug
safety at Dr. Falk Pharma GmbH, which manufactures budes-
onide. The other authors have no conflict of interest.
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