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Effect of Single and Repeated Doses of Ketoconazole on the Pharmacokinetics of Roflumilast and
Roflumilast N-Oxide
Gezim Lahu, Andreas Huennemeyer, Oliver von Richter, Robert Hermann, Rolf Herzog, Nigel McCracken and Karl
Zech
J. Clin. Pharmacol. 2008; 48; 1339 originally published online Aug 29, 2008;
DOI: 10.1177/0091270008321941

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Effect of Single and Repeated Doses of
Ketoconazole on the Pharmacokinetics of
Roflumilast and Roflumilast N-Oxide
Gezim Lahu, MSc, Andreas Huennemeyer, MSc, MD,
Oliver von Richter, PhD, Robert Hermann, MD, Rolf Herzog,
Nigel McCracken, PhD, and Karl Zech, PhD
Effects of single and multiple doses of oral ketoconazole
on roflumilast and its active metabolite, roflumilast N-
oxide, were investigated in healthy subjects. In study 1,
subjects (n = 26) received oral roflumilast 500 μg once
daily for 11 days and a concomitant 200-mg single dose
of ketoconazole on day 11. In study 2, subjects (n = 16)
received oral roflumilast 500 μg on days 1 and 11 and
a repeated dose of ketoconazole 200 mg twice daily from
days 8 to 20. Coadministration of single-dose ketocona-
zole with steady-state roflumilast increased the AUC of
roflumilast by 34%; Cmax was unchanged. For roflumilast
N-oxide, AUC and Cmax decreased by 12% and 20%,
R oflumilast (3-cyclopropylmethoxy-N-(3,5-
dichloropyridin-4-yl)-4(difluoromethoxy) benza-
mide) is a targeted, oral, once-daily phosphodiesterase
4 (PDE4) inhibitor in clinical development for chronic
obstructive pulmonary disease (COPD) and bronchial
asthma.1,2 In clinical studies, roflumilast 500 μg has
been demonstrated to be safe and clinically effective
in the treatment of COPD and asthma.3,4
From Nycomed GmbH (formerly ALTANA Pharma AG), Konstanz,
Germany (Mr Lahu, Dr Huennemeyer, Mr Herzog, Dr McCracken,
Dr von Richter, Dr Zech); University of Tuebingen, Institute for Toxicology,
Pharmacy and Chemistry, Tuebingen, Germany (Mr Lahu); and Clinical
Research Appliance, Radolfzell, Germany (Dr Hermann). Dr von Richter
and Dr Hermann are fellows of the American College of Clinical
Pharmacology. Submitted for publication March 17, 2008; revised ver-
sion accepted June 8, 2008. Address for correspondence: Gezim Lahu,
MSc, Nycomed GmbH, Department of Pharmacometrics and
Pharmacokinetics, Byk-Gulden-Str. 2, 78467 Konstanz, Germany;
e-mail: gezim.lahu@nycomed.com.
DOI: 10.1177/0091270008321941
J Clin Pharmacol 2008;48:1339-1349
DRUG INTERACTIONS
respectively. Repeated doses of ketoconazole increased
the AUC and Cmax of roflumilast by 99% and 23%,
respectively; for roflumilast N-oxide, AUC was unchanged,
and Cmax decreased by 38%. No clinically relevant
adverse events were observed. Coadministration of keto-
conazole and roflumilast does not require dose adjust-
ment of roflumilast.
Keywords: Drug-drug interactions; healthy subjects;
ketoconazole; Phase 1 study; roflumilast
Journal of Clinical Pharmacology, 2008;48:1339-1349
© 2008 the American College of Clinical Pharmacology
Orally administered roflumilast 500 μg is absorbed
readily and almost completely, with an average
absolute bioavailability of 79%.5 The maximum plasma
concentration (Cmax) is attained after about 0.5 to 1
hour.5 In healthy adult subjects, roflumilast expo-
sure is dose-proportional over 250 to 1000 μg.6 The
mean elimination plasma disposition half-life time
(t1/2) of roflumilast is about 17 hours.7 In humans,
roflumilast is mainly cleared by biotransformation
via cytochrome P450 enzymes CYP3A4 and 1A2
isozymes to its active metabolite, roflumilast N-
oxide. Roflumilast N-oxide is subsequently dealky-
lated by CYP3A4, glucuronidated, and eliminated
renally. Roflumilast N-oxide has a phosphodi-
esterase selectivity profile and in vivo potency sim-
ilar to roflumilast.8
The total systemic exposure (ie, AUC) of the
N-oxide metabolite exceeds that of roflumilast by
about 10-fold. Following oral administration of
roflumilast to healthy subjects, Cmax of roflumilast
N-oxide is reached after 4 to 8 hours and remains
1339
 LAHU ET AL
constant for about 6 to 8 hours. The apparent termi-
nal plasma t1/2 of roflumilast N-oxide is about 27
hours. The plasma protein binding of both roflumilast
and roflumilast N-oxide is high (98.9% and 96.6%,
respectively). The N-oxide is estimated to account for
about 90% of roflumilast’s overall pharmacologic
effects (ie, total PDE4 inhibitory activity).9,10
Ketoconazole is an imidazole antifungal drug
used for treatment of fungal infections such as oral
thrush, candidiasis, and hard to treat fungal skin
infections. The maximum recommended daily dose
of ketoconazole is 400 mg. This can be administered
orally either as a single dose of 400 mg or as 200 mg
twice daily. Ketoconazole is a potent competitive
inhibitor of CYP3A4, with some inhibitory activity
of CYP1A2, CYP1A1, and CYP2C19; the Ki values
for these enzymes are 0.0054 μM, 32 μM, 36.6 nM,
and 6.9 μM, respectively.11-14 Several other CYP
enzymes as well as ABCB1 (P-glycoprotein) are also
inhibited by ketoconazole.15 The US Food and Drug
Administration (FDA) recommends that researchers
investigate ketoconazole when evaluating in vivo
drug-drug interaction that involve CYP3A4.16
Because ketoconazole is a potent, competitive,
and short-acting CYP3A4 inhibitor (t1/2 of about 2.5
hours)17 of CYP enzymes that are relevant also for the
metabolism of roflumilast and its major metabolite,
roflumilast N-oxide, we evaluated the interaction
between these 2 drugs. Given the pharmacokinetic
properties of roflumilast, 2 studies were performed.
The focus of these studies was to investigate the
effect of CYP3A4 inhibition by ketoconazole (after a
single dose of ketoconazole and after a repeated dose
of ketoconazole in steady state) on the metabolism of
roflumilast. For safety reasons, the single-dose study
preceded the repeated-dose study.
METHODS
Study Subjects
In both studies, healthy male and female subjects
were enrolled. Their health status was confirmed
by medical history, physical examination, electro-
cardiogram (ECG), and clinical laboratory measure-
ments. Women were of nonchildbearing potential
(ie, they were postmenopausal with 2 years since
the last menstrual period or had a tubal ligation or
hysterectomy, and they were not breastfeeding).
The study protocol of study 1 was reviewed
and approved by the Ethics Committee for Medical
Research of the University of the Free State,
1340 • J Clin Pharmacol 2008;48:1339-1349
Bloemfontein, South Africa. The protocol and the
approval of the ethics committee were submitted
to the South African Medicines Control Council.
The study protocol of study 2 was reviewed and
approved by the institutional review board of MDS
Pharma Services (New Orleans, Louisiana, USA).
The studies were conducted in accordance with
the Declaration of Helsinki (Somerset West Amend-
ment, 1996) and the International Conference on
Harmonisation (ICH) Guideline on Good Clinical
Practice (Note for Guidance on Good Clinical Practice
[CPMP/ICH/135/95], January 17, 1997) (study 1) and
in accordance with Food and Drug Administration
Regulations (Title 21 Code of Federal Regulations
[21 CFR], Parts 50, 56, and 312) (study 2). The
studies were performed at FARMOVS-PAREXEL,
Bloemfontein, South Africa (study 1) and at MDS
Pharma Services, Inc, New Orleans, Louisiana
(study 2). Written informed consent was obtained
from each subject prior to study-related procedures.
Study Design
The design of the studies reported here was based on
the published data for ketoconazole inhibition of
CYP3A4 and on the recommendations of the FDA
guidelines. As reported by Olkkola et al,18 inhibition
of CYP3A4 by ketoconazole can be achieved after
administering 400 mg once daily for 4 days, lead-
ing to a 16-fold change in midazolam AUC, follow-
ing oral administration of 7.5 mg midazolam.
Others have reported that 3 doses of oral 200-mg
ketoconazole were sufficient to achieve an 11-fold
change in midazolam AUC, following oral adminis-
tration of 6.5 mg midazolam.19 Finally, the current
FDA concept paper on drug-drug interaction recom-
mends the highest dose of inhibitor within the short-
est possible dosing interval to be used as precipitant
and specifically emphasizes that the inhibitor
should be present throughout the elimination phase
of the probe compound.16
Single-Dose Ketoconazole (Study 1)
This was an open-label, nonrandomized, 1-sequence,
2-period, 2-treatment crossover study in 26 healthy
male and female subjects who received oral roflumi-
last 500 μg once daily from days 1 to 11. On day
11, a single dose of oral ketoconazole 200 mg and
roflumilast 500 μg was administered together.
Blood samples for pharmacokinetic analysis were
taken over a full 24-hour roflumilast dosing interval
on study day 10 (reference: roflumilast alone at
 KETOCONAZOLE-ROFLUMILAST DRUG-DRUG INTERACTION
steady state) and day 11 (test: roflumilast at steady
state with single-dose ketoconazole) at predose and
0.5, 1, 1.5, 2, 3, 4, 6, 8, 10, 12, 14, and 24 hours after
morning administration. The sample collected at 24
hours of day 10 and the predose sample of day 11
were identical.
Repeated-Dose Ketoconazole (Study 2)
This was an open-label, nonrandomized, 1-sequence,
2-period, 2-treatment crossover study in 16 healthy
male and female subjects who received a single oral
dose of roflumilast 500 μg on days 1 and 11.
Ketoconazole 200 mg twice daily was administered
orally from days 8 to 20, in the morning and in the
evening, every 12 hours. On day 11, roflumilast and
the morning dose of ketoconazole were adminis-
tered together. Blood for pharmacokinetic analysis
was taken after the roflumilast dose on day 1 at pre-
dose and 0.25, 0.5, 1, 1.5, 2, 3, 4, 6, 8, 12, 16, 24, 36,
48, 72, 96, and 120 hours. After the roflumilast dose
on day 11, blood was taken at the same time inter-
vals and also at 144, 168, 192, 216, and 240 hours.
The 24-, 48-, 72-, 96-, 120-, 144-, 168-, 192-, and 216-
hour blood samples were taken before administra-
tion of ketoconazole on days 12 to 20.
Study Conduct
Roflumilast and ketoconazole tablets were adminis-
tered with about 240 mL of tap water. On blood
sampling days, subjects began fasting about 8 hours
prior to the administration of roflumilast and con-
tinued fasting for at least 4 hours after drug admin-
istration. Subjects were required to abstain from any
food or drink (except water) at least 4 hours prior
to any safety laboratory evaluations and 8 hours
prior to the start of blood sample collection. Non-
caffeinated drinks (except grapefruit juice) could be
consumed with meals and the evening snack. Lunch
was provided about 4 hours after drug administra-
tion. Lunch could differ slightly among the subjects;
each subject received an identical lunch on blood
sampling days. During the 14 days prior to study
drug administration, none of the subjects was
allowed to take any prescription or nonprescription
drugs that were expected to affect the pharmacokinetic
parameters measured in these studies. Roflumilast
500-μg tablets were provided by ALTANA Pharma
AG (Konstanz, Germany). Ketoconazole 200-mg
tablets were purchased from commercial sources.
Study 1 was performed in South Africa; Nizoral
200-mg tablets were purchased (Janssen-Cilag, Neuss,
DRUG INTERACTIONS
Germany, charge no. 02CL475). Study 2 was per-
formed in the United States; ketoconazole 200-mg
tablets were purchased (Mylan Pharmaceuticals,
Morgantown, WV, charge no. 1L1820).
Blood Sample Processing
At sampling times specified above, venous blood (5-
9 mL) was drawn into lithium-heparinized tubes.
The blood was mixed by gentle inversion and cen-
trifuged at 1200 g for 15 minutes in a refrigerated
centrifuge. Plasma was separated from whole blood
within 30 minutes of collection and stored within 1
hour of collection at –20°C until analysis.
Safety and Tolerability Assessment
Safety monitoring included physical examinations,
vital signs (heart rate, blood pressure), 12-lead ECG,
clinical laboratory tests, and recording adverse
events. Blood pressure and pulse rate (both in sitting
position) were measured at screening, predose, on
days when blood sampling was scheduled, and at the
end of the study. Clinical chemistry, hematology, and
urine analysis were performed at screening, on the
blood sampling day, and at the end of the study. A 12-
lead ECG was performed at screening, at frequent
intervals during the study, at the end of the study, and
12 hours after the end of the study. Adverse events
were monitored throughout the study.
Determination of Roflumilast and Roflumilast
N-Oxide in Human Plasma
In both studies, plasma concentrations of roflumilast
and roflumilast N-oxide were determined using a
validated high-performance liquid chromatography
with tandem mass spectrometry (HPLC/MS/MS)
assay with [D5]roflumilast and [D5]roflumilast N-
oxide as internal standards. The assay was validated
according to standards recommended by the regula-
tory authorities.20 The assay was linear between 0.04
and 60 μg/L for roflumilast and roflumilast N-oxide.
The lower limit of quantitation (LLOQ) was 0.04 μg/L
for both analytes, using a sample volume of 0.5 mL.
Sample preparation was performed using liquid/
liquid extraction. Chromatography was performed
on a Luna (Phenomenex) C18(2), 5-μm, 100-Å, 50 ×
2-mm analytical column using a linear gradient with
acetonitrile/5 mM aqueous ammonium acetate as
eluent. Roflumilast was monitored in the positive
ion mode with the mass transition of m/z 403.1 to
1341
 LAHU ET AL
187.1; the respective internal standard was analyzed
with the mass transition of m/z 408.2 to 190.0.
Roflumilast N-oxide was monitored in the positive
ion mode with the mass transition of m/z 419.0 to
187.1; the respective internal standard was analyzed
with the mass transition of m/z 424.2 to 190.0. No
interconversion of roflumilast N-oxide back to
parent compound roflumilast, either in plasma or in
the MS source, was observed. Ketoconazole did not
interfere with the quantification of roflumilast or
roflumilast N-oxide; this was determined before the
sample analysis.
In study 1, the interday precision (between-day
coefficient of variation) for roflumilast ranged
between 4.03% and 9.16%, and interday accuracy
ranged between 98.5% and 101.3%. For roflumilast
N-oxide, the interday precision ranged between
1.72% and 3.67%, and interday accuracy ranged
between 101.4% and 106.5%. In study 2, the inter-
day precision (between-day coefficient of variation)
for roflumilast ranged between 7.71% and 8.76%,
and interday accuracy ranged between 98.0% and
98.8%. For roflumilast N-oxide, the interday preci-
sion ranged between 3.13% and 5.89%, and interday
accuracy ranged between 99.4% and 105.6%.
Statistical Methods
Sample Size
For study 1, which evaluated the effects of a single
dose of ketoconazole on steady-state roflumilast, no
formal sample size calculation was performed; the
number of subjects was set to 26, which is often
used as a sample size for drug-drug interaction stud-
ies. For study 2, which evaluated the effect of
steady-state ketoconazole on single-dose roflumilast,
the considerations of sample size were based on the
experience of study 1. Thus, for the second study,
the sample size calculation was performed for an
assumed ratio of 150% (ratio of roflumilast together
with ketoconazole/roflumilast) for both observed
Cmax and total exposure (AUC) and an associated
90% confidence interval (CI) of 100% to 200%.
When investigating the effect of a single dose of
ketoconazole on steady-state roflumilast, the mean
square error (MSE) of ln(Cmax) was 0.031671 (the
maximum MSE observed in the study); the MSE of
ln(AUC0-∞) was smaller than 0.0062091, and the MSE
of ln(Cmax) of roflumilast N-oxide also was smaller
than the MSE of ln(Cmax) of roflumilast. Assuming
variability equivalent to that found in study 1, at
least 12 subjects were required for the second study
1342 • J Clin Pharmacol 2008;48:1339-1349
to provide greater than 80% and 90% power to state
that the upper limit of 90% CI would be less than
200% for the Cmax and AUC ratio.
Pharmacokinetic Parameters
Pharmacokinetic parameter estimates for roflumilast
and roflumilast N-oxide were calculated by non-
compartmental analysis using WinNonlin Version
4.0.1 (Pharsight, Mountain View, California, USA). The
observed Cmax with the corresponding times of obser-
vation (tmax) were obtained directly from the data.
The slope of the visually identified terminal log-
linear portion (λz) of each individual plasma con-
centration-time curve was determined by log-linear
regression. The apparent terminal plasma disposi-
tion t1/2 was calculated as ln(2)/λz. Estimates of the
area under the plasma concentration-time curve
(AUC0-last and AUC0-24) were obtained in study 1
(single-dose ketoconazole) using linear trapezoidal
integration up to the last sampling point. Estimates
of total AUC (AUC0-∞) in study 2 (repeated-dose
ketoconazole) were derived by AUC0-last + Clast/λz,
where Clast is the last quantifiable plasma concentra-
tion. The apparent oral clearance (CL/F, where F
denotes the fraction of the dose absorbed) was cal-
culated using the formula CL = dose(oral)/AUC0-∞
and dose(oral)/AUC0-24. The relationship between
the formation clearance (CLf) of roflumilast N-oxide
from roflumilast, the metabolic clearance of roflumi-
last N-oxide (CLm), the exposure to roflumilast
(AUC), and the exposure to roflumilast N-oxide
(AUCm) was described according to the following
equation:
AUCm CLf
= (1)
AUC CLm
Total PDE4 Inhibitory Activity (tPDE4i)
After administration of roflumilast, the total PDE4
inhibition in humans is due to the combined effect
of both roflumilast and roflumilast N-oxide. The
active metabolite roflumilast N-oxide accounts for
about 90% of roflumilast’s overall pharmacologic
effects. To estimate the combined PDE4 inhibition of
roflumilast and roflumilast N-oxide in humans after
administration of roflumilast, we established the
parameter termed the total PDE4 inhibitory activity
(tPDE4i), which is based on the following equation9:
[AUCrof × furof] [AUCrofNO × furofNO]
+ = tPDE4i (2)
[IC50,rofNO × τ] [IC50,rofNO × τ]
 KETOCONAZOLE-ROFLUMILAST DRUG-DRUG INTERACTION
Table I Demographic Data
Repeated-Dose Roflumilast
Baseline Characteristics With Single-Dose Ketoconazole (Study 1)
Total number of subjects 26
Male 19a
Female 7 3
Age, y
Mean (range) 24.6 (19-40)
Race 21 White
5 Black
Weight, kg
Mean (range) 70.2 (56-91)
Height, cm
Mean (range) 172.7 (154-193)
Body mass index, kg/m2
Mean (range) 23.5 (19.4-27.9)
a. One subject withdrew from the study on day 1 before drug intake.
where AUCrof and AUCrofNO are the AUC of roflumilast
and roflumilast N-oxide (μg⋅h/L; either AUC0-∞ fol-
lowing a single dose or AUC0-τ following multiple
doses at steady state), furof and furofNO are the unbound
fraction of roflumilast (0.011) and roflumilast N-oxide
(0.0034), IC50,rof and IC50,rofNO are the roflumilast and
roflumilast N-oxide concentration (μg/L) resulting in
50% PDE4 inhibition in vitro (0.7 nM [0.3 μg/L] for
roflumilast8 and 2.0 nM [0.8 μg/L] for roflumilast
N-oxide), and τ is the dosing interval (24 hours).
Statistical Analysis
Pharmacokinetic parameters, including log-trans-
formed Cmax, AUC, and oral plasma clearance (CL/F)
values, were analyzed with an analysis of variance
(ANOVA) model consisting of subjects as random
effects and treatments as fixed effects. Model-based
90% CIs for test (roflumilast with ketoconazole) as a
percentage of reference (roflumilast alone) were
generated using the linear mixed-effect module
of WinNonlin Version 4.0.1. This procedure was
equivalent to the two 1-sided test.21 Lack of an effect
of ketoconazole on roflumilast was concluded if the
90% CIs for Cmax, AUC, and tPDE4i (based on log-
transformed data) were within the standard equiva-
lence acceptance range of 80% to 125%.
RESULTS
Study Subjects
The demographic characteristics of the subjects
included in the 2 studies were comparable (Table I). In
DRUG INTERACTIONS
Single-Dose Roflumilast
With Repeated-Dose Ketoconazole (Study 2)
16
13
33.2 (19-48)
5 White
11 Black, non-Hispanic
78.4 (52.7-112.7)
172.8 (160-188)
26.2 (18.7-34.8)
study 1 (single-dose ketoconazole), of the 26 enrolled
subjects, 2 discontinued the study due to adverse
events: 1 subject on day 1 before taking any study
drug and 1 subject on day 11. Thus, data from 24
subjects were evaluated. In study 2 (repeated-dose
ketoconazole), 16 subjects were enrolled. Although
1 subject discontinued the study due to an adverse
event, all data points were available for evaluation.
Pharmacokinetics Evaluation
Single-Dose Ketoconazole (Study 1)
Results for the mean roflumilast and roflumilast N-
oxide pharmacokinetic parameters, ratios, and CIs
are presented in Table II. At steady state, roflumilast
coadministration with a single dose of ketoconazole
200 mg led to an increase in the mean AUC0-24 of
roflumilast by 34%; Cmax remained unchanged.
Compared with the parent compound roflumilast,
ketoconazole affected the pharmacokinetics of roflu-
milast N-oxide to a lesser extent, as seen by the less
pronounced effect on the mean AUC0-24 (decrease by
12%) and on Cmax (decrease by 20%). The pharma-
cokinetic changes for roflumilast and roflumilast N-
oxide plasma concentration-time profiles are shown
in Figure 1A and 1B, respectively.
The effect of a single dose of ketoconazole on
the steady-state roflumilast AUC0-24 was more pro-
nounced than on the steady state of roflumilast
N-oxide, as reflected by a decrease in the AUCroflumilast
N-oxide/AUCroflumilast ratio from 12.7 (steady-state roflu-
milast, alone) to 8.2 (steady-state roflumilast with
1343
 LAHU ET AL

Table II Summary of Steady-State Roflumilast and Roflumilast N-Oxide Pharmacokinetic Parameters

(Geometric Least Squares Mean) From Study 1 After Administration of Roflumilast 500 μg Alone
(Reference) and Together With a Single Dose of Ketoconazole 200 mg (Test)
Steady-State Roflumilast Steady-State Roflumilast
With Single-Dose Ketoconazole Alone Ratio %
(Test) n = 24 (Reference) n = 24 (90% Confidence Interval)

Roflumilast
Cmax, μg/L 9.24 8.48 106 (98-116)
AUC0-24, μg⋅h/L 69.9 50.1 134 (129-139)
tmax, h (median) 1.5 1.0 NA
Roflumilast N-oxide
Cmax, μg/L 31.1 38.1 80 (77-83)
AUC0-24, μg⋅h/L 576 641 88 (86-89)
tmax, h (median) 4.0 4.0 NA
AUCroflumilast N-oxide/AUCroflumilast 8.2 12.7 64 (NA)
tPDE4ia 1.10 1.21 91 (89-92)
NA, not applicable.
a. Total PDE 4 inhibitory activity is expressed as the sum of the total exposure of roflumilast and roflumilast N-oxide (see equation (2)).

A B
plasma concentration (µg/L)
plasma concentration (µg/L)

8.0 Roflumilast alone 40.0 Roflumilast alone

Roflumilast + Ketoconazole
Roflumilast N-oxide

Roflumilast + Ketoconazole

6.0 30.0
Roflumilast

4.0 20.0

2.0 10.0

0.0 0.0

0 5 10 15 20 25 0 5 10 15 20 25
Time (h) Time (h)

Figure 1. Plasma concentration-time profiles (mean and SEM) of (A) roflumilast and (B) roflumilast N-oxide following repeated-dose
administration of oral roflumilast 500 μg once daily alone and coadministered with a single dose of oral ketoconazole 200 mg twice daily.

single-dose ketoconazole) (Table II). The tPDE4i
activity did not change, irrespective of whether rof-
lumilast was administered alone or together with a
single dose of ketoconazole, as defined by the equiv-
alence criteria of 80% to 125%.
Repeated-Dose Ketoconazole (Study 2)
At steady-state ketoconazole, coadministration with
single-dose roflumilast 500 μg led to an increase in
mean AUC∞ and Cmax of roflumilast by about 99%
and 23%, respectively (Table III). In parallel, a
decrease in the apparent clearance of roflumilast
from 11.3 μg⋅h/L (single-dose roflumilast, alone) to
5.7 μg⋅h/L (single-dose roflumilast with steady-state
ketoconazole) was observed.
The pharmacokinetic changes are illustrated in
Figure 2A and 2B, displaying roflumilast and roflu-
milast N-oxide plasma concentration-time profiles,
respectively. The terminal plasma disposition t1/2 of
roflumilast changed from 23.7 hours (roflumilast

1344 • J Clin Pharmacol 2008;48:1339-1349

 KETOCONAZOLE-ROFLUMILAST DRUG-DRUG INTERACTION

Table III Summary of Roflumilast and Roflumilast N-Oxide Pharmacokinetic Parameters (Geometric Least
Squares Mean) From Study 2 After a Single Oral Dose of Roflumilast 500 μg Alone (Reference) and
Coadministered With Ketoconazole 200 mg Twice Daily in Steady State (Test)
Single-Dose Roflumilast Single-Dose Roflumilast
With Steady-State Ketoconazole Alone Ratio %
(Test) n = 16 (Reference) n = 16 (90% Confidence Interval)

Roflumilast
Cmax, μg/L 6.94 5.63 123 (106-143)
AUC0-last, μg⋅h/L 83.7 41.6 201 (175-232)
AUC0-∞, μg⋅h/L 88.2 44.3 199 (171-231)
CL/F, L/h 5.7 11.3 50 (43-58)
tmax, h 2.16 1.69 NA
t1/2, h 39.7 23.7 NA
Roflumilast N-oxide
Cmax, μg/L 6.69 10.7 62 (57-68)
AUC0-last, μg⋅h/L 586 540 109 (98-121)
AUC0-∞, μg⋅h/L 611 595 103 (92-115)
tmax, h 21.5 9.6 NA
t1/2, h 43.5 31.5 NA
AUCroflumilast N-oxide/AUCroflumilast 6.9 13.4 52 (NA)
tPDE4ia 1.22 1.12 109 (97-122)
NA, not applicable.
a. Total PDE 4 inhibitory activity is expressed as the sum of the total exposure of roflumilast and roflumilast N-oxide (see equation (2)).

alone) to 39.7 hours (roflumilast with ketocona-
zole). Under both conditions, the tmax of roflumilast
was only slightly affected after concomitant drug
administration, changing from 1.7 hours (roflumi-
last alone) to 2.2 hours (roflumilast with ketocona-
zole) (Table III).
In contrast to the alterations seen for the parent
drug roflumilast, the AUC of roflumilast N-oxide
remained unchanged; the Cmax of roflumilast N-oxide
decreased by about 38%. Notably, the tmax of roflu-
milast N-oxide was 9.6 hours (roflumilast alone) as
compared with 21.5 hours (roflumilast with keto-
conazole).
The effect of steady-state ketoconazole on both
roflumilast AUC0-last and AUC0-∞ was more pro-
nounced than on the respective AUCs of roflumilast
N-oxide. This was reflected by a decrease in the ratio
AUCroflumilast N-oxide/AUCroflumilast from 13.4 (roflumilast
alone) to 6.9 (roflumilast with ketoconazole).
Overall, ketoconazole did not affect the tPDE4i
activity of roflumilast (Figure 3).
Safety Evaluation
Single-Dose Ketoconazole (Study 1)
During study 1, a total of 57 adverse events were
reported by 21 of the 25 subjects. Of these, 20
subjects reported 51 adverse events during roflumi-
last administration, and 3 subjects reported 6
adverse events during coadministration of roflumi-
last with ketoconazole. The intensity of the adverse
events was mostly mild (n = 42); some were moder-
ate (n = 14) or severe (n = 1). Headache was the
most frequent adverse event when roflumilast was
given alone or during coadministration of roflumilast
with ketoconazole. No clinically relevant changes
were seen for hematology, clinical chemistry, or
urine analysis parameters. Change from baseline for
vital signs and ECG parameters was comparable after
administration of roflumilast alone and roflumilast
together with ketoconazole. One adverse event (mod-
erate tracheitis) was classified as serious because it
required hospitalization; the subject recovered
within 10 days without sequel. This subject dropped
out of the study due to this adverse event.
Repeated-Dose Ketoconazole (Study 2)
During the study, 21 adverse events were reported
by 11 of the 16 subjects. Two subjects reported 4
adverse events after roflumilast was given alone, 7
subjects reported 8 adverse events after concomi-
tant intake of roflumilast and ketoconazole, and 7
subjects reported 9 adverse events during adminis-
tration of ketoconazole alone. Adverse events were

DRUG INTERACTIONS 1345

 LAHU ET AL

A B
8 14
Roflumilast alone Roflumilast alone
plasma concentration (µg/L)

plasma concentration (µg/L)

Roflumilast + Ketoconazole 12 Roflumilast + Ketoconazole

Roflumilast N-oxide
6
10
Roflumilast

8
4
6

2 4

0 0

0 40 80 120 160 200 240 0 40 80 120 160 200 240

Time (h) Time (h)

Figure 2. Plasma concentration-time profiles (mean and SD) of oral (A) roflumilast and (B) roflumilast N-oxide following a single dose
of roflumilast 500 μg alone and coadministered with oral ketoconazole 200 mg twice daily in steady state.

as related to the administration of study drug (keto-

2.50 conazole). On study day 14, alanine aminotrans-
ferase (ALT) was 190 (reference range, 2-60 U/L),
Reference ratiofor AUC0-∞

2.25
Point estimate of Test/

2.00 exceeding the protocol-specified withdrawal crite-

1.75
1.50
1.25
1.00
0.75
Roflumilast Roflumilast N-oxide
Figure 3. Point estimates of test/reference (T/R) ratios and 90%
confidence intervals for roflumilast, roflumilast N-oxide, and the
total PDE4 inhibitory activity (tPDE4i) following administration of
roflumilast alone and with steady-state ketoconazole 200 mg
twice daily (study 2). The shaded area represents the bioequiva-
lence acceptance range of 0.8 to 1.25.
mostly mild or moderate in intensity; they were
assessed by the investigator as not related (n = 4),
unlikely related (n = 5), possibly related (n = 6),
probably related (n = 2), and definitely related (n =
1) to the study medication. Headache and diarrhea
were the most common adverse events during the
study. Laboratory values did not show any clinically
relevant changes between the screening and post-
study examination. One subject was withdrawn due
to an adverse event of abnormal liver function tests
on study day 14. This adverse event was assessed
rion of ALT >2 times the upper limit of normal
(ULN), and the subject was withdrawn from the
study. The ALT then ranged from 196 to 273
between days 16 and 21 before starting a decline to
a normal value of 51 on day 35. This subject’s aspar-
tate aminotransferase (AST) level also was elevated
tPDE4i beginning on study day 14 and increased to about
1.5 to 2 times the ULN before returning to within
normal limits by study day 28.
DISCUSSION
The 2 studies presented here are part of a drug-drug
interaction program for roflumilast—a PDE4 inhibitor,
currently in clinical studies for the treatment of
COPD and asthma. Initially, we investigated the
extent of interaction between single-dose ketocona-
zole and roflumilast (study 1) and later the effect
of steady-state ketoconazole on roflumilast and
its main active metabolite, roflumilast N-oxide
(study 2).
The study design for study 2 addresses the phar-
macokinetic properties of roflumilast, roflumilast
N-oxide, and ketoconazole (tmax and t1/2) and allows
evaluation of the extent of drug-drug interaction of
roflumilast and ketoconazole. The tmax of roflumilast
and roflumilast N-oxide occurs at different times,

1346 • J Clin Pharmacol 2008;48:1339-1349

 KETOCONAZOLE-ROFLUMILAST DRUG-DRUG INTERACTION
and a significant disparity in tmax is anticipated between
roflumilast, roflumilast N-oxide, and ketoconazole.
Dosing of subjects in study 2 with ketoconazole was
200 mg twice a day (maximum recommended dose
400 mg a day). The dosing schedule was chosen
such that the tmax for all compounds coincided with
the competitive and reversible inhibition of CYP3A4
by ketoconazole. Furthermore, the typical popula-
tion values for the t1/2 of roflumilast (17 hours) and
roflumilast N-oxide (27 hours) are substantially longer
than that of ketoconazole (2.5 hours). The chosen
study design (study 2) takes into account the short-
est dosing interval of ketoconazole and the presence
of ketoconazole throughout the elimination phase of
roflumilast. Both of these aspects are aligned with
the recommendations from the FDA guideline on
drug-drug interaction when the probe has a long ter-
minal elimination t1/2 and a substantially different
tmax from the inhibitor.16
The results from these studies indicate that the
effects of single-dose ketoconazole on steady-state
roflumilast were less pronounced than the effects of
steady-state ketoconazole. These findings are in line
with the competitive inhibition of CYP3A4 by keto-
conazole and its high clearance rate, both of which
lead to temporary inhibition of CYP3A4. Thus, after
a single dose of ketoconazole, the AUC of steady-
state roflumilast increased by 34%, whereas the Cmax
was unchanged. When roflumilast was administered
in steady-state ketoconazole, the AUC increase was
about 2-fold, and Cmax increased by 23%, reflecting
the sustained inhibition of CYP3A4 by steady-state
ketoconazole.
For the active metabolite roflumilast N-oxide, the
Cmax decreased by about 12% after a single dose of
ketoconazole (study 1) and by 38% when roflumi-
last was administered to steady-state ketoconazole
(study 2). These results are consistent with a
delayed formation of roflumilast N-oxide, reaching
its peak at 21 hours after roflumilast administration
and temporary inhibition of CYP3A4 by ketocona-
zole. The results of both studies are consistent with a
limited effect of ketoconazole on CYP3A4 during the
metabolism of roflumilast to roflumilast N-oxide,
emphasizing the important role of CYP3A4 in the for-
mation of the active N-oxide metabolite. The expo-
sure of roflumilast and roflumilast N-oxide, seen
when roflumilast was coadministered at steady-state
ketoconazole, most accurately reflects the clinical
setting due to the repeated-dosing regimen.
The metabolism of roflumilast to roflumilast
N-oxide is affected by the formation clearance (CLf)
of roflumilast N-oxide from roflumilast and by the
metabolic clearance of roflumilast N-oxide (CLm), as
DRUG INTERACTIONS
described in equation (1). Although CLm was not
directly estimated in this study, the data indicate that
the CLm of roflumilast N-oxide may have decreased
when roflumilast was coadministered with steady-
state ketoconazole. After a single dose of ketocona-
zole, roflumilast N-oxide exposure was reduced by
12%, reflecting the effect of CYP3A4 inhibition on the
CLf of the metabolite. This effect was not observed
upon coadministration with steady-state ketoconazole.
A possible explanation for this could be a counter-
balancing effect on CLf by the first dose of ketocona-
zole and on CLm by the second dose of ketoconazole,
administered 12 hours later, showing no apparent
effect on roflumilast N-oxide exposure. This finding
is also supported by in vitro studies, which showed
that dealkylation of roflumilast N-oxide is catalyzed
via CYP3A4 and by extrahepatic CYP1A1 and
CYP2C19 (data not shown).
Similarly, a decrease in CLf of roflumilast N-oxide
caused by ketoconazole is consistent with the in
vitro metabolism, confirming that the formation of
this metabolite is mediated partly by CYP3A4 and
CYP1A2. A decrease in CLf and CLm is consistent
with in vitro data, considering that CYP3A4 not only
mediates the clearance of roflumilast but, to a differ-
ent extent, also affects the formation and elimination
of roflumilast N-oxide.
Based on the results of the presented 2 studies, it
can be concluded that moderate inhibition of roflu-
milast metabolism takes place after the coadminis-
tration of single and repeated doses of ketoconazole.
Coadministration of roflumilast with the maximum
recommended dose of ketoconazole showed a dou-
bling of roflumilast AUC. In contrast, no change in
AUC was observed for the active metabolite roflumi-
last N-oxide. These results indicate that concomitant
administration of roflumilast with potent CYP3A4
inhibitors would not have any effect on roflumilast’s
major active metabolite because CYP3A4 is involved
to a different extent in the formation and clearance
of the metabolite.
In vivo, the total PDE4 inhibition in humans is
considered to be due to the combined effect of both
roflumilast and roflumilast N-oxide, whereby roflu-
milast N-oxide accounts for about 90% of roflumi-
last’s overall pharmacologic effects (equation (2)).
This concept has been used to assess roflumilast
drug-drug interaction studies and studies in special
populations.9 Administration of roflumilast alone or
together with ketoconazole had no effect on tPDE4i
because concomitant ketoconazole did not alter the
exposure to roflumilast N-oxide. Considering that
disposition of roflumilast and roflumilast N-oxide is
mediated not just by CYP3A4 but also by CYP1A2,
1347
 LAHU ET AL
CYP1A1, and CYP2C19 suggests that their specific
inhibitors cannot significantly alter the tPDE4i due
to the presence of alternative pathways. This, however,
was not the case for multiple pathway inhibitors
such as fluvoxamine (CYP1A2, CYP2C19), which
showed a greater effect due to its inhibitory potential on
all CYPs involved in the metabolism of roflumilast.22
In respiratory diseases such as COPD and asthma,
ketoconazole is used as a systemic treatment to treat
oral thrush and candidiasis, which are some of the
undesirable effects of inhaled corticosteroids. Our
results show that ketoconazole may be coadminis-
tered with roflumilast in these patients without
affecting the tPDE4i activity. During both studies
and for both drugs, no new untoward safety signals
were identified. Adverse events observed during rof-
lumilast administration were consistent with the
known safety and tolerability profile of roflumilast.
The overall number and nature of observed adverse
events suggest that coadministration of roflumilast
and of the highest recommended daily dose of keto-
conazole does not substantially affect the known
safety and tolerability profile of either drug.
CONCLUSIONS
In conclusion, after coadministration of ketoconazole,
pharmacokinetic changes in the AUC and Cmax of rof-
lumilast were observed. However, these changes do
not translate into a significant change in the tPDE4i
activity mediated by roflumilast and its active metabo-
lite, roflumilast N-oxide. Considering that the thera-
peutic range of roflumilast is related to tPDE4i and the
safety assessment, it can be concluded that concomi-
tant administration of ketoconazole and roflumilast
does not require any dose adjustment of roflumilast.
The authors thank Hermann Mascher and Dr Daniel Mascher
(pharm-analyt Labor GmbH, Baden, Austria) for roflumilast and rof-
lumilast N-oxide bioanalytics, Professor Martin Elmlinger (Nycomed
GmbH, Konstanz Germany) and Dr Peter Van Ess for valuable advice
during the evaluation of results, and Dr Kathy B. Thomas and Dr
Angela Schilling (formerly of Nycomed GmbH, Konstanz Germany)
for helpful suggestions during the preparation of the manuscript.
Financial disclosure: This study was sponsored by Nycomed
GmbH (formerly ALTANA Pharma AG), Konstanz, Germany.
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