More on grapefruit juice and drugs

A few weeks back, I wrote about drug interactions. On the recommendation of my editor (it was originally for the local paper,) I'd removed the details of how certain drugs are metabolized - the part I found most interesting, and the part he thought would most likely lead to bored and frustrated readers.

At the time I'd agreed with him and cut. But then, over the Thanksgiving Holiday, when I'd jokingly commented on the cranberry juice cocktail my friend was about to finish off, she said,

"...but I only take the Lipitor at night. Drinking a glass of cranberry juice during the day shouldn't matter."

Maybe, maybe not. I don't know much about the combination of Lipitor (atorvastatin calcium) and cranberry juice but the comment reminded me of why I'd written about the details of drug metabolism in the first place.

While the science of drug metabolism is complicated enough, when one adds the potential for drug-drug or drug-food interactions the level of complexity can skyrocket.

First, a quick introduction to drug metabolism. Lipitor is a drug metabolized primarily by enzymes belonging the CYP detoxification or drug metabolizing system. Years ago the CYP system was one of the few recognized detoxification systems in the body. That is, a collection of enzymes working together to metabolize toxic chemicals and send them on their way before they can cause any damage. Back then we knew of only a couple of enzymes, now there are dozens and dozens grouped into "families" of CYP enzymes. In the case of Lipitor, CYP3A4 is key for proper metabolism and eventual excretion of the drug.

For chemicals that require metabolism by CYP enzymes prior to excretion, the CYPs play an important role in determining the half-life of a drug or chemical.

Half-life refers to the length of time required for a drug or chemical to be reduced to one-half the initial concentration. Knowing the half-life is necessary to determing dosage ensuring that 1) there is sufficient levels of drug in the system and 2) concentrations don't get too high that they become toxic.

Anything that screws with the half-life of a chemical is potentially very dangerous. For chemicals that must be metabolized in order to be excreted, an increase in CYP metabolism would reduce half-life, resulting in drug concentrations that may no longer effective. Conversely, a reduction of CYP metabolism, or inhibition of metabolism can increase half-life, causing drugs to accumulate to toxic, possibly even lethal concentrations.

And even asking "what's the half-life" of a drug under normal conditions isn't so simple. Take the example of Lipitor. While the parent compound Lipitor (the actual drug that you ingest) may have a half-life of only fourteen hours, the metabolites of the drug - which in this case are most active - have a much longer half-life of twenty to thirty hours. That means that it can take up to thirty hours for half the initial concentration of active metabolites to exit your body.

Now lets consider the interaction between grapefruit juice (really certain chemicals in grapefruit juice) which act as inhibitors of CYP3A4. In this case, those CYP enzymes responsible for metabolic breakdown of Lipitor would be inhibited, essentially extending the half-life of the drug possibly leading to potentially toxic concentration of the drug.

And, what makes this all really complicated is that depending on how an inhibitor like grapefruit juice does it's dirty-work, the inhibitory effects may either very short-term or can last for days. In the case of grapefruit, according to one article in Pharmacy Times drinking grapefruit juice not only has immediate (within 30 minutes) impacts on metabolism, but, depending on how long and how much one has been drinking, inhibitory effects can last up to three days. This is because the chemicals responsible for inhibition by grapefruit juice, essentially combine irreversibly to CYP3A4, taking them out of action for good, necessitating synthesis of new enzyme.

Phew - maybe my editor was right! Well, you get the point I hope.

When taking new drugs or adding new food and beverages to your diet, it's well worth the little extra effort to inform your doctor or your pharmacist of the changes.

Bodily defense: detoxification update

Years ago as a budding toxicologist I studied a fascinating system called cytochrome P450, so called because under certain conditions one could measure a peak at the light wavelengths of 450nm. What was so fascinating was that it was, at the time, one of the few recognized detoxification systems. That is, this system, which consists of various proteins, could metabolize certain toxic chemicals and send them on their way out of the body. Now almost two decades later a recent paper, published in Developmental Biology by Goldstone and others, presents the “chemical defensome,” described as an “integrated network of genes and pathways that allow an organism to mount an orchestrated defense against toxic chemicals.” Though it sounds like something that belongs on a football field, it’s a little more highly evolved than that.

Back in the simple days, before scientists had the capability to identify each and every gene in our bodies, toxicology students studied the fate of fairly simple chemicals like polyaromatic hydrocarbons – those ubiquitous chemicals found in combustion products from the tip of a cigarette to the tip of your tailpipe – chemicals that basically sealed their doom by activating the system responsible for their own destruction. You see this particular detoxification system required activation or binding to a receptor, sort of the old lock and key - now an obsolete analogy but still good enough to get the basic idea across. A chemical binds to a receptor, and opens the door for specific proteins to be produced, in this case specific cytochrome P450 enzymes, which then go to work metabolizing the chemical sending it on its way to eventual detoxification.

Learning the story of P450 and polyaromatic chemicals was a must for nascent toxicologists. That was back in the old days, before the cigarette industry acknowledged the connection between inhaling a lungful of chemicals and cancer, but even back then we all knew that once some of those chemicals entered the lungs, little PAH keys entered PAH locks, or what we called aryl hydrocarbon receptors, activating genes necessary for P450 induction all around the body, in lung cells, liver cells, and kidney cells. We also knew that this process presented the proverbial “double-edged sword.” That is, detoxification of some chemicals, particularly PAHs, required several steps – some of them resulting in activation of a chemical to a more toxic or reactive state – before eventual detoxification and finally excretion. And, in the case of PAH, activation meant that the reactive PAH could bind to genetic material in way that could promote formation of cancerous tumors. We also knew there was a genetic component - even if we didn't know much about the genetics of the system. We knew then that the detoxification pathway proceeded differently and to different extents in some folks compared with others.

But at that time we were aware of just a few kinds of P450 enzymes, and, we had no idea of the breadth of the detoxification system, or the basic genetics of a system we now know we share with creatures ranging from tunicates, our slimy cousins that still cling to rocks by the seashore, to the pesky fruit flies that zip around the bruised fruit in my kitchen.

It made sense though, that given the harsh earthly conditions in which they evolved, our ancestors would need to protect themselves from constant chemical assault. But even so, back then, toxicologists wondered if receptors like the aryl hydrocarbon or PAH receptor evolved as a defense mechanism, or if its role in detoxification of foreign chemicals was a surreptitious side effect. Maybe, the system had evolved to deal with what are called endogenous chemicals, a way to get rid of the body’s own powerful chemicals once they no longer serve their purpose, like steroids for example (which, at least in my teen seems toxic enough, though to be fair, without them we’d probably still be clinging to rocks in some tide pool alongside our tunicate cousins.)

Now, a decade and a half later, scientists have unveiled a diverse and sprawling system of detoxification, or defense mechanisms from a plethora of P450 enzymes to antioxidants responsible for quenching the highly reactive oxygen produced by many metabolic processes protecting us from a range of potentially deadly chemicals, including microbial and plant toxins, PAHs and heavy metals.

In a paper that goes into genetic detail way beyond what my tunicate brain can comprehend, J.V. Goldstone and others introduce these systems collectively as a “defensome,” a fascinating concept of protective mechanisms that we humans take for granted, as we challenge our bodies with ever more complex combinations of naturally occurring and manmade chemicals. Let's just hope that unlike the typical Superbowl blowouts, we won't suffer a similar defensome overload, leaving us at the mercy of our natural and unnatural environment.

All the genetic details (and a hint to the youthful secrets of elderly sea urchins) can be found in Goldstone, J.V. et al. “The chemical defensome: Environmental sensing and response genes in the Strongylocentrotus purpuratus genome,” Developmental Biology 300:366-384.