The Journal of Clinical

Pharmacology
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Influence of Different Proton Pump Inhibitors on Activity of Cytochrome P450 Assessed by [13
C]-Aminopyrine Breath Test
Chise Kodaira, Shinya Uchida, Mihoko Yamade, Masafumi Nishino, Mutsuhiro Ikuma, Noriyuki Namiki, Mitsushige
Sugimoto, Hiroshi Watanabe, Akira Hishida and Takahisa Furuta
J Clin Pharmacol published online 17 March 2011
DOI: 10.1177/0091270010397728
The online version of this article can be found at:
http://jcp.sagepub.com/content/early/2011/03/16/0091270010397728
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Influence of Different Proton Pump Inhibitors

on Activity of Cytochrome P450 Assessed by
[13C]-Aminopyrine Breath Test
Chise Kodaira, MD, Shinya Uchida, PhD, Mihoko Yamade, MD,
Masafumi Nishino, MD, Mutsuhiro Ikuma, MD, PhD, Noriyuki
Namiki, PhD, Mitsushige Sugimoto, MD, PhD, Hiroshi Watanabe,
MD, PhD, Akira Hishida, MD, PhD, and Takahisa Furuta, MD, PhD

Aminopyrine is metabolized by cytochrome P450 (CYP)

in the liver. The investigators evaluated influences of
different PPIs on CYP activity as assessed by the
[13C]-aminopyrine breath test ([13C]-ABT). Subjects were
15 healthy volunteers with different CYP2C19 status (5
rapid metabolizers [RMs], 5 intermediate metabolizers
[IMs], and 5 poor metabolizers [PMs]). Breath samples
were collected before and every 15 to 30 minutes for
3 hours after oral ingestion of [13C]-aminopyrine 100 mg
on day 8 of each of the following regimens: control; omeprazole 20 mg and 80 mg, lansoprazole 30 mg, and rabeprazole 20 mg. Changes in carbon isotope ratios in
carbon dioxide (13CO2/12CO2) in breath samples were
measured by infrared spectrometry and expressed as

delta-over-baseline (DOB) ratios (). Mean areas under

the curve of DOB from 0 to 3 h (AUC0-3h of DOB) were
significantly decreased by omeprazole 20 mg and lansoprazole 30 mg but not by rabeprazole 20 mg. Conversely,
higher PPI dose (ie, omeprazole 80 mg) seemed to further
decrease AUC0-3h of DOB in RMs but increased it in PMs.
Omeprazole and lansoprazole at the standard doses
inhibit CYP activity but rabeprazole does not, whereas
high-dose omeprazole seems to induce CYPs.

such as clarithromycin, metronidazole, and amoxicillin.3,4 Recently, prescription of a PPI has been recommended by the American College of Cardiology
Foundation, the American College of Gastroenterology,
and the American Heart Association for patients with
a risk of peptic ulcer and/or patients taking 2 or more
antiplatelet agents.5-7 Therefore, PPI is now used in
patients who are taking a variety of therapeutic agents.
PPIs are mainly metabolized in the liver by cytochrome P450 (CYP) 2C19. Several reports have
described drugdrug interactions with PPIs via
hepatic CYPs.8 Because patients often take various
drugs for concomitant illnesses, a risk of drugdrug
interactions exists, and such interactions may
increase the risk of adverse drug events or altered
efficacy of therapeutic agents.9 However, the effect of
PPIs on CYP activity has not been fully elucidated.
Aminopyrine is metabolized in the liver by CYPs,
such as CYP2C19, 1A2, 3A4, and 2C9, after absorption
through the intestine.10,11 During the metabolism of
aminopyrine by CYPs, CO2 is generated. Therefore,
when [13C]-labeled aminopyrine is metabolized by

roton pump inhibitors (PPIs), such as omeprazole,

lansoprazole, and rabeprazole, have been widely
used as potent inhibitors of gastric acid secretion. PPIs
strongly inhibit gastric acid secretion by irreversibly
binding to the proton pump (H+, K+-ATPase) in gastric
parietal cells.1,2 The major indications for PPIs are
acid-related diseases, such as peptic ulcer, gastroesophageal reflux disease, Zollinger-Ellison syndrome, and the eradication of Helicobacter pylori
infection in combination with antimicrobial agents

From the First Department of Medicine, Hamamatsu University School of

Medicine (Dr Kodaira, Dr Yamade, Dr Nishino, Dr Ikuma, Dr Hishida);
Department of Pharmacy Practice and Science, School of Pharmaceutical
Sciences, University of Shizuoka (Dr Uchida, Dr Namiki); Center for
Clinical Research, Hamamatsu University School of Medicine (Dr
Sugimoto, Dr Furuta); and Department of Clinical Pharmacology and
Therapeutics, Hamamatsu University School of Medicine (Dr Watanabe).
Submitted for publication August 11, 2010; revised version accepted
December 19, 2010. Address for correspondence: Takahisa Furuta, MD,
PhD, Center for Clinical Research, Hamamatsu University School of
Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192,
Japan; e-mail: furuta@hama-med.ac.jp.
DOI: 10.1177/0091270010397728

Keywords: [13C]-aminopyrine breath test; cytochrome

P450; proton pump inhibitor; CYP2C19
Journal of Clinical Pharmacology, XXXX;XX:xxx-xxx
2011 The Author(s)

J Clin Pharmacol xxxx;xx:x-x

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KODAIRA ET AL
Table I Demographic Characteristics of Study Subjects Among CYP2C19 Genotype Status

CYP2C19 genotype
Age, y
Sex, n M/F
Height, cm
Body weight, kg

RM (n = 5)

IM (n = 5)

PM (n = 5)

P Value

*1/*1

*1/*2: n = 3
*1/*3: n = 2

21.2 1.3
3/2
167.6 5.5
57.6 5.9

21.8 0.5
4/1
172.4 5.3
58.0 7.2

*2/*2: n = 0
*2*/3: n = 5
*3/*3: n = 0
22.6 1.1
4/1
171.4 5.6
61.0 6.8

.141
.687
.370
.687

BMI, body mass index; IM, intermediate metabolizer; PM, poor metabolizer; RM; rapid metabolizer.

CYPs, 13CO2 is generated. Accordingly, 13CO2 after

ingestion of [13C]-aminopyrine is considered as a good
marker of CYP activity, which is the so-called
[13C]-aminopyrine breath test ([13C]-ABT).12,13 As noted
before, PPIs will be used in many patients treated with
a variety of medicines. Therefore, drugdrug interaction associated with PPIs via P450 will be of a great
clinical problem. Thus, we evaluated the influences of
different PPIs on CYP activity using the [13C]-ABT.
Methods
Subjects
Blood samples were obtained from 50 H pylori
seronegative healthy Japanese volunteers after obtaining written informed consent from each of them.
After genotyping of these samples, we enrolled randomly selected 5 rapid metabolizers (RMs), 5 intermediate metabolizers (IMs), and 5 poor metabolizers
(PMs) in this study after obtaining written informed
consent again. Demographic characteristics of 15 subjects are demonstrated in Table I. They had no history
of peptic ulcer, hepatic disorders, cardiovascular disorders, renal diseases, or other serious conditions.
Subjects had consumed no alcohol or taken any drugs
for 1 month prior to this study. Smoking was prohibited during the study period. No significant differences in age, male/female ratio, or body weight were
seen among the 3 CYP2C19 genotype groups (Table I).
All subjects provided written informed consent prior
to enrollment.
[13C]-ABT and Study Protocol
[13C]-ABT was performed as followed. After collection
of baseline breath samples after overnight fasting, 100
mg of oral [13C]-aminopyrine (N,N-dimethyl-[13C]aminopyrine; 99%) dissolved in 100 mL of water
was dosed to each of the subjects. Breath samples were

collected before and 15, 30, 45, 60, 75, 90, 105, 120,
150, and 180 minutes after oral [13C]-aminopyrine
administration. Changes in the carbon isotope ratio
(13CO2/12CO2) in carbon dioxide from breath samples
were measured with infrared spectrometry (PocOne;
Otsuka Electronics, Hirakata, Japan) and were expressed
as a delta-over-baseline (DOB) ratio (), representing
the change in 13CO2/12CO2 ratio in breath samples collected before and after [13C]-aminopyrine ingestion.
[13C]-ABT was performed with different regimens:
control and after dosing with omeprazole 20 mg and
80 mg (Omepral, AstraZeneca Pharmaceutical, Osaka,
Japan), lansoprazole 30 mg (Takepron, Takeda Pharmaceutical, Osaka, Japan), and rabeprazole 20 mg
(Pariet, Eisai, Tokyo, Japan) for 8 days. The washout
interval between different regimens was greater than
2 weeks.
Plasma concentrations of [13C]-aminopyrine were
measured at 0, 0.5, 1, 2, and 3 hours after oral ingestion of [13C]-aminopyrine at the baseline regimen and
at 2 omeprazole regimens (20 mg and 80 mg). Plasma
omeprazole level was measured at 3.5 hours after
omeprazole dosing. We then evaluated how each PPI
influenced the pharmacokinetics of aminopyrine. The
study protocol was approved by the Ethics Committee
of Hamamatsu University School of Medicine.
Genotyping of CYP2C19
CYP2C19 genotyping was performed using a PCRRFLP method using DNA extracted from whole
blood.14 Subjects were classified into 3 genotype
groups: RMs (*1/*1); IMs (*1/*2 or *1/*3); and PMs
(*2/*2, *3/*3, or *2/*3).
Measurements of Plasma Concentration of
[13C]-Aminopyrine and Omeprazole
Plasma concentrations of [13C]-aminopyrine were
determined by high-performance liquid chromatog-

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INFLUENCE OF PROTON PUMP INHIBITORS ON CYP

Statistical Analysis
Numerical values are given as mean standard
deviation (SD). Pharmacokinetic parameters for
[13C]-aminopyrine and omeprazole were estimated by
noncompartmental analysis. Maximum plasma concentration (Cmax) and time at maximum plasma concentration (Tmax) were estimated directly from
observed plasma concentrationtime data. The area
under the curve (AUC) for plasma concentration or
DOB versus time from 0 to 3 hours after administration of [13C]-aminopyrine was calculated by the linear
trapezoidal rule for the observed values. Statistically
significant differences in pharmacokinetic and pharmacodynamic parameters among the 3 different
CYP2C19 genotype groups were assessed using 1-way
analysis of variance followed by Scheff multiple
comparison test. Presence or absence of changes in
pharmacological parameters was assessed by paired t
test. All P values were 2-sided, and P < .05 was considered statistically significant.
Results
Characteristics of Subjects in Relation to
CYP2C19 Genotype Status
Table I summarizes demographic characteristics of
study subjects among CYP2C19 genotype status.
There were no statistically significant differences in

AUC0-3h of Plasma 13C-aminopyrine

B
Oral clearance of 13C-aminopyrine

raphy (HPLC)/mass spectrometry (LC/MS). Briefly,

plasma samples (0.1 mL) and 20 ng of antipyrine (1 mL
in methanol) as an internal standard were mixed and
centrifuged at 10000g for 10 minutes. A 10-L aliquot
was injected into the HPLC apparatus and analyzed
using an analytical column (Symmetry C18, 5 m, 2.1
mm 150 mm; Waters, Milford, Massachusetts) and a
guard column (Symmetry C18, 3.5 m, 2.1 mm 10
mm; Waters) with the mobile phase (methanol/0.1%
formic acid, 70:30, vol/vol) delivered at a flow rate of
0.2 mL/min at 40C. The mass spectrometer was operated in positive ionization mode with selected ion
recording acquisition at 189.1 m/z for antipyrine and
234 m/z for [13C]-aminopyrine. The limit of quantification was 0.1 g/mL, and the intra-assay coefficient of
variation was less than 13.5%. The run time of the
assay was 4.5 minutes. The retention times of antipyrine and [13C]-aminopyrine were 2.19 and 1.96 minutes, respectively.
Plasma concentrations of omeprazole were determined by LC/MS as previously reported,15 with
minor modification.

(hg/mL)
.8
.7

P = .042

.6

R 2 = .116

.5
.4
.3
.2
.1
0
0

(L/h)
55
50
45
40
35
30
25
20
15
10
5
0
0

30
15
20
25
10
AUC0-3h of DOB (hg/mL)

35

40

P = .002
R 2 = .297
5

10

15

20

25

30

35

40

AUC0-3h of DOB (hg/mL)

Figure 1. Association of [13C]-aminopyrine breath test ([13C]-ABT)

with pharmacokinetic parameters of [13C]-aminopyrine. (A) Area
under the curve from 0 to 3 hours (AUC0-3h) of [13C]-aminopyrine
shows a significant inverse association with AUC0-3h of delta-overbaseline (DOB) of [13C]-ABT. (B) Oral clearance of [13C]-aminopyrine
shows a significant association with AUC0-3h of DOB of [13C]-ABT.

means of age, height, and body weight and in male/

female ratio among 3 CYP2C19 genotype groups.
[13C]-ABT and Pharmacokinetics
of [13C]-Aminopyrine
Figure 1 shows the association of [13C]-ABT results
with metabolic parameters of [13C]-aminopyrine.
AUC0-3h of [13C]-aminopyrine showed a significant
inverse correlation with AUC0-3h of DOB (R2 = 0.116,
P = .042; Figure 1A). Similarly, clearance of plasma
[13C]-aminopyrine showed a significant association
with AUC0-3h of DOB (R2 = 0.297, P = .002; Figure 1B).
Together, [13C]-ABT reflects the metabolic disposition
3

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KODAIRA ET AL
Table II Plasma Kinetic Parameters of
[13C]-Aminopyrine With or Without Omeprazole
20mg Treatment (Adjusted Weight-Dose)
T1/2, h
CLoral, L/h
Tmax, h
Cmax, g/mL
AUC0-3h, hg/mL

0.035
0.405
0.018
0.026
0.052

0.020
0.204
0.011
0.011
0.023

After OPZ

0.056
0.323
0.833
0.026
0.053

0.033
0.176
0.408
0.011
0.022

Control

10

OPZ 20 mg
LPZ 30 mg

P Value

.002
.048
.313
.827
.807

AUC0-3h, area under the curve from 0 to 3 hours; CLoral, oral clearance;
Cmax, maximum drug concentration, OPZ, omeprazole; T1/2, half lifeperiod; Tmax, time at maximum drug concentration.

of [13C]-aminopyrine and could offer a marker of

hepatic CYP activity.
Influences of PPIs on Pharmacokinetics
of [13C]-ABT
Table II summarizes the pharmacokinetic parameters of [13C]-aminopyrine with or without omeprazole. Half-life (T1/2) of [13C]-aminopyrine after
omeprazole 20 mg treatment was significantly longer
than the control (P = .002). Similarly, oral clearance
of [13C]-aminopyrine after dosing of omeprazole 20
mg was significantly decreased in comparison with
the control (P = .048; Table II).
Figure 2 shows time course changes in DOB of
[13C]-ABT with or without different PPIs. DOB of
[13C]-ABT was decreased when omeprazole 20 mg
was dosed 30 minutes before [13C]-aminopyrine
ingestion in comparison with control. Similarly, lansoprazole 30 mg decreased the DOB of [13C]-ABT.
However, rabeprazole 20 mg did not affect the DOB
of [13C]-ABT in comparison with control.
Figure 3 shows the influences of different PPIs on
AUC0-3h of DOB. Mean AUC0-3h of DOB at the control
level was 21.9 6.0%h, compared with 19.2 5.4 %h
after omeprazole 20 mg, 19.6 5.6%h after lansoprazole 30 mg, and 21.2 5.7%h after rabeprazole
20 mg. Administration of omeprazole 20 mg and lansoprazole 30 mg significantly decreased AUC0-3h of
DOB in comparison with the control (P = .021 and
P = .018), whereas rabeprazole 20 mg did not.
Figure 4 shows the effect of CYP2C19 genotypes
on DOB of [13C]-ABT. DOB of PMs was lower than
those of IMs and RMs. Mean DOB in PMs, RMs, and
IMs were 18.0 5.8%h, 23.6 3.1%h, and 24.1
7.4%h, respectively.

DOB

Baseline

(%)

RPZ 20 mg

7
6
5
0

(h)

Figure 2. Time course changes of delta-over-baseline (DOB) of

[13C]-aminopyrine with and without different proton pump inhibitors (PPIs). The mean of DOB of [13C]-aminopyrine was most
decreased by omeprazole (OPZ) 20 mg in comparison with the
control. Similarly, it was decreased by lansoprazole (LPZ) 30 mg.
However, it did not change by rabeprazole (RPZ) 20 mg in comparison with the control. Bars indicate standard deviation (SD).

Figure 5 shows the influences of different PPIs on

AUC0-3h for DOB of [13C]-ABT as a function of CYP2C19
genotypes. Omeprazole 20 mg significantly decreased
AUC0-3h for DOB of [13C]-ABT in IMs. In contrast, no
significant differences were observed with lansoprazole 30 mg or rabeprazole 20 mg.
Influences of Omeprazole 80 mg on [13C]-ABT
Figure 6 compares the influences of omeprazole 20
mg and 80 mg on DOB as a function of CYP2C19
genotype status. In RMs, DOB appeared further
decreased from 23.6 3.1% to 21.9 3.8% and
20.5 5.1% increasing the dose of omeprazole from
20 mg to 80 mg (Figure 6A and 6B). In IMs, omeprazole 20 mg significantly decreased DOB from 24.1
7.4% to 18.7 5.6% (P = .048); however, this
decrease in DOB was ameliorated with omeprazole
80 mg (23.0 4.5%) (Figure 6C and 6D). In PMs,
omeprazole 20 mg appeared to decrease DOB from
18.0 5.8% to 17.1 6.3%, but omeprazole 80 mg
increased DOB to 21.3 6.7% (P = .042 for control
and .029 for omeprazole 20 mg) (Figure 6E and 6F).
AUC0-3h of DOB appeared decreased with the dose
of omeprazole in RMs (although statistically not significantly), that in IMs significantly decreased by
omeprazole 20 mg but returned to the control level
by omeprazole 80 mg, and that in PM did not
decreased by omeprazole 20 mg but significantly
increased by omeprazole 80 mg (Figure 6G).

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INFLUENCE OF PROTON PUMP INHIBITORS ON CYP

P = .018
(%h)
24

14

23

12

22

10

21

DOB

AUC0-3h of DOB

(%)

P = .021

20
19
18

2
Control

OPZ
20 mg

LPZ
30 mg

Figure 3. Influence of different proton pump inhibitors (PPIs) on

area under the curve from 0 to 3 hours (AUC0-3h) of delta-overbaseline (DOB). The mean of AUC0-3h of DOB was significantly
decreased by omeprazole (OPZ) 20 mg and lansoprazole (LPZ) 30
mg in comparison with the control, but not by rabeprazole (RPZ)
20 mg. Bars indicate standard deviation (SD).

Con

OPZ

LPZ

AUC0-3 h of DOB

RPZ

28
26
24
22
20
18
16
0

Con

OPZ

3 (h)

Figure 4. Effect of CYP2C19 genotypes on delta-over-baseline

(DOB) of [13C]-aminopyrine breath test ([13C]-ABT). The mean
DOB in poor metabolizers (PMs) was lowest of the 3 CYP2C19
genotype groups. Bars indicate standard deviation (SD).

IM
P = .048

(%h)
28
26
24
22
20
18
16
0

PM

RPZ
20 mg

RM

IM

6
4

RM

PM

LPZ

RPZ

28
26
24
22
20
18
16
0

Con

OPZ

LPZ

RPZ

Figure 5. Influence of different proton pump inhibitors (PPIs) on area under the curve from 0 to 3 hours (AUC0-3h) for delta-over-baseline
(DOB) of [13C]-aminopyrine breath test ([13C]-ABT) as a function of CYP2C19 genotype status. Omeprazole (OPZ) significantly decreased
DOB in IMs of CYP2C19. Bars indicate standard deviation (SD). Con, control; IM, intermediate metabolizer; RM, rapid metabolizer; PM,
poor metabolizer.

With omeprazole 20 mg, plasma concentration of

omeprazole at 3.5 hours after administration was lowest
in RMs and highest in PMs. Similarly, when omeprazole 80 mg was dosed, plasma concentration of omeprazole at 3.5 hours was the lowest in RMs and the highest
in PMs. However, the PM/RM ratio of plasma omeprazole levels appeared to decrease after increasing the
omeprazole dose from 20 mg to 80 mg. When plasma
omeprazole dose was increased from 20 mg to 80 mg,
omeprazole level increased approximately 3.4 times in
RMs. However, in PMs, the increase in omeprazole
level was smaller (1.8 times) than that in RMs (Table III).

Discussion
In the present study, we first confirmed that [13C]-ABT
reflected the pharmacokinetics of aminopyrine.
Then we evaluated the influence of 3 PPIs on CYP
activity using [13C]-ABT and found that the different
PPIs influenced the activity of CYPs in different
degrees and that the influence of PPIs on CYPs
depended on CYP2C19 genotype status. Different
PPIs were found to influence the activity of CYPs to
differing degrees, and the influence of PPIs on
CYP2C19 depended on genotype. We also found that

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KODAIRA ET AL

B RM by OPZ 80 mg
12

10

10

DOB (%)

DOB (%)

RM by OPZ 20 mg
12

6
4
2
0

10

6
4

6
4
2

2
n=5
1

3 (h)

PM by OPZ 20 mg

DOB (%)

10

DOB (%)

12

10

6
4
2
2

AUC0-3h of DOB (%h)

G 35

3 (h)

6
4
2

n=5
1

n=5
1

PM by OPZ 80 mg

12

3 (h)

12

10

D IM by OPZ 80 mg

DOB (%)

DOB (%)

n=5

3 (h)

IM by OPZ 20 mg
12

4
2

n=5
1

3 (h)
P = .048

n=5
1

3 (h)

P = .042
P = .029

30
25
20
15
10
5
0

Con OPZ OPZ

20 mg 80 mg
RM
n=5

Con OPZ OPZ

20 mg 80 mg
IM
n=5

Con OPZ OPZ

20 mg 80 mg
PM
n=5

Figure 6. Influence of omeprazole (OPZ) 20 mg and 80 mg on deltaover-baseline (DOB) of [13C]-aminopyrine breath test ([13C]-ABT) as a
function of CYP2C19 genotype status. (A) DOB of [13C]-ABT with or
without OPZ 20 mg in rapid metabolizers (RMs) of CYP2C19. (B)
DOB of [13C]-ABT with or without OPZ 80 mg in RMs of CYP2C19.
(C) DOB of [13C]-ABT with or without OPZ 20 mg in intermediate
metabolizers (IMs) of CYP2C19. (D) DOB of [13C]-ABT with or without OPZ 80 mg in IMs of CYP2C19. (E) DOB of [13C]-ABT with or
without OPZ 20 mg in poor metabolizers (PMs) of CYP2C19. (F) DOB
of [13C]-ABT with or without OPZ 80 mg in PMs of CYP2C19. (G)
Influences of OPZ 20 mg or 80 mg on AUC0-3h of DOB (%h) in RMs,
IMs, and PMs of CYP2C19. DOB was most decreased by OPZ in a
dose-dependent manner in RMs of CYP2C19 (compare A with B);
however, this decrease was not statistically significant (G). That in
IMs was decreased by OPZ 20 mg but not by OPZ 80 mg (C, D, and
G). That in PMs seemed slightly decreased by OPZ 20 mg but significantly increased by OPZ 80 mg (E, F, and G). Bars indicate standard deviation (SD). o, without omeprazole; , with omeprazole.

a higher dose of PPI (ie, omeprazole 80 mg) seemed

to induce CYPs in IMs and PMs of CYP2C19; however, P value did not reach the statistical significance because our sample size was small.
Various reports have described drugdrug interactions of PPIs with other drugs. McCarthy et al8
reported that concomitant use of a PPI significantly
increased the incidence of adverse events for other
drugs with potential for interaction with PPIs,
such as warfarin, clarithromycin, and corticosteroids. Ishizaki et al16 reported that omeprazole
significantly decreased the mean clearance of
diazepam and increased its half-life, AUC for plasma
concentrationtime, and mean residence time in
RMs and IMs of CYP2C19. Recently, prophylactic
use of a PPI in patients treated with clopidogrel was
reported to attenuate the antiplatelet function of
clopidogrel, which is associated with increased risk
of adverse outcomes in comparison with clopidogrel
treatment without a PPI.17 Interestingly, clopidogrel
inhibits CYP2C19-dependent hydroxylation of omeprazole in subjects carrying CYP2C19 *1/*1 but not
CYP2C19 *2/*2 or *3.18 Thus, the interaction of a PPI
with other drugs thus sometimes depends on
CYP2C19 genotypes, as observed in the present study.
The [13C]-ABT has been used to evaluate CYP
activity.19 However, little study has been done on
the relationship between [13C]-ABT and pharmacokinetics of [13C]-aminopyrine. The present study
measured plasma [13C]-aminopyrine levels and
DOB using breath samples at the same time after
ingestion of [13C]-aminopyrine and confirmed
that [13C]-ABT results reflect the pharmacokinetics
of [13C]-aminopyrine. We are therefore sure
that [13C]-ABT offers a simple, noninvasive tool
to evaluate the activity of CYPs, as reported
previously.10,20,21
We found that CYP2C19 is strongly involved in
the metabolism of aminopyrine, as DOB differed
among different CYP2C19 genotype groups: DOB in
PMs of CYP2C19 was lower than RMs and IMs at
baseline, indicating aminopyrine as one substrate of
CYP2C19. Drugdrug interactions might thus reasonably occur between aminopyrine and other substrates of CYP2C19, such as PPIs. However,
differences exist in metabolic dispositions among
different PPIs, associated with the different potential
for drugdrug interactions via CYPs.22 Omeprazole
is mainly metabolized by CYP2C19, and lansoprazole is metabolized by CYP2C19 and CYP3A4,
whereas CYPs play a smaller role in the metabolism
of rabeprazole in comparison with other PPIs.23 This
difference in the metabolic dispositions of 3 PPIs
seemed compatible with the present results.

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INFLUENCE OF PROTON PUMP INHIBITORS ON CYP

Table III Plasma Concentration of Omeprazole 20 mg and 80 mg at 3.5 Hours After Administration
Among Different CYP2C19 Genotype Status
OPZ 20 mg, ng/mL
OPZ 80 mg, ng/mL

RM (n = 5)

IM (n = 5)

PM (n = 5)

P Valuea

164.8 85.8
550.9 304.5

526.2 377.4
1046.7 402.9

650.3 302.2*
1167.9 496.7**

.091
.084

IM, intermediate metabolizer; OPZ, omeprazole; PM, poor metabolizer; RM, rapid metabolizer.
a. Analysis of variance.
*
RM vs PM; P = .039.
**
RM vs PM; P = .042.

Giannini et al10 compared drugdrug interactions

among omeprazole, lansoprazole, and pantoprazole
(PPZ) during H pylori eradication therapy using
[13C]-ABT and suggested that the administration of
these PPIs and antimicrobial agents did not seem to
influence global liver metabolic function, whereas
omeprazole confirmed a somewhat greater inhibitory
effect on [13C]-aminopyrine. Giannini et al24 also
reported in another study that rabeprazole did not
inhibit CYP activity in eradication of H pylori with
antimicrobial agents. These investigators performed
[13C]-ABT during rabeprazol in patients with gastroesophageal reflux disease and showed that 1-week,
full-dose rabeprazole does not display any significant
interactions with CYPs.25 The present study reconfirmed that rabeprazole has little inhibitory effect on
CYP activity as assessed by [13C]-ABT. Our study also
demonstrated that omeprazole and lansoprazole
inhibit CYP activity. Close attention must therefore be
paid to the risk of drugdrug interactions when using
lansoprazole as well as omeprazole.
In the present study, at the usual standard doses
of PPIs, omeprazole showed the most evident inhibitory effect on CYPs, particularly in IMs of CYP2C19.
Interestingly, at a high dose of omeprazole (80 mg),
CYP activity was most inhibited in RMs but appeared
in turn slightly increased in PMs. Henry et al26 tested
for drugdrug interactions at 2 dose levels of omeprazole (30 mg and 60 mg/d) using [14C]-ABT and
showed that drugdrug interactions should be
assessed when large doses of omeprazole are being
used. In contrast, Diaz et al27 reported that omeprazole
selectively increased CYP1A1 and 1A2 activities in
human liver microsomes. Rost et al28,29 reported that
omeprazole induced CYP1A2 in a dose-independent
manner. Our results suggest that omeprazole inhibits
CYP activity in a dose-dependent manner in RMs but
induces some CYPs, probably such as CYP1A1 and
CYP1A2, in PMs. Because clearance of omeprazole
is decreased in IMs and PMs in comparison with

RMs, a very high concentration of omeprazole is

attained in IMs and PMs when a high dose of omeprazole (ie, 80 mg) is dosed. Therefore, in IMs of
CYP2C19, an increased dose of a PPI not only inhibits some CYP activity but also induces other CYPs.
As a result, the inhibitory effects of PPI on CYPs
appear to be offset by the induction of other CYPs.
Similarly, higher plasma levels of omeprazole in
PMs might further induce CYPs, and [13C]-ABT
results were therefore increased by omeprazole
80 mg in PMs. When omeprazole dose was increased
from 20 mg to 80 mg, the increase in plasma omeprazole level in PMs was smaller than that in
RMs, indicating that other CYPs to metabolize omeprazole are induced in PMs. Therefore, we think
that patterns of drugdrug interactions of PPIs are
influenced by CYP2C19 genotypes as well as
PPI dose.
Finally, the present results must be interpreted
within the following study limitations. First, the
duration of PPI dosing in this study was short.
Second, the sample size was small. Third, subjects
were young healthy volunteers, not patients. These
study results must thus be considered as preliminary, and further studies are required to evaluate the
clinical significance of the influence of different
PPIs on CYPs. In any case, our results clearly demonstrate that short-term treatment with different
PPIs inhibits CYP activity to differing degrees.
Among PPIs, omeprazole and lansoprazole significantly inhibit CYPs. Moreover, the influence of PPIs
on CYPs depended on CYP2C19 genotype status as
well as PPI doses. Therefore, possible drugdrug
interactions should be taken into consideration in
relation to CYP2C19 genotype status and PPI dose
when a PPI is used in patients treated with other
substrates of CYP2C19. We think that [13C]-ABT
could be useful for predicting drugdrug interactions. The clinical usefulness of this test should be
verified in a future study.

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KODAIRA ET AL
Acknowledgements
We thank Ms Kageyama for her help in measuring
plasma concentrations of [13C]-aminopyrine and
omeprazole.
Financial disclosure: This work was supported by a grant-inaid from the Ministry of Education, Culture, Sports, Science and
Technology of Japan (20590718).
No authors had any conflicts of interest related to this study.

References
1. Satoh H, Inatomi N, Nagaya H, et al. Antisecretory and antiulcer activities of a novel proton pump inhibitor AG-1749 in dogs
and rats. J Pharmacol Exp Ther. 1989;248:806-815.
2. Nagaya H, Satoh H, Kubo K, Maki Y. Possible mechanism for the
inhibition of gastric (H+ + K+)-adenosine triphosphatase by the proton
pump inhibitor AG-1749. J Pharmacol Exp Ther. 1989;248:799-805.
3. Blum RA. Lansoprazole and omeprazole in the treatment of acid
peptic disorders. Am J Health Syst Pharm. 1996;53:1401-1415.
4. Furuta T, Futami H, Arai H, Hanai H, Kaneko E. Effects of lansoprazole with or without amoxicillin on ulcer healing: relation
to eradication of Helicobacter pylori. J Clin Gastroenterol. 1995;
20(suppl 2):S107-S111.
5. Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA 2008
expert consensus document on reducing the gastrointestinal risks
of antiplatelet therapy and NSAID use: a report of the American
College of Cardiology Foundation Task Force on Clinical Expert
Consensus Documents. Circulation. 2008;118:1894-1909.
6. Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA 2008
expert consensus document on reducing the gastrointestinal risks of
antiplatelet therapy and NSAID use: a report of the American
College of Cardiology Foundation Task Force on Clinical Expert
Consensus Documents. J Am Coll Cardiol. 2008;52:1502-1517.
7. Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA
2008 expert consensus document on reducing the gastrointestinal
risks of antiplatelet therapy and NSAID use. Am J Gastroenterol.
2008;103:2890-2907.
8. McCarthy DM, McLaughlin TP, Griffis DL, Yazdani C. Impact of
cotherapy with some proton pump inhibitors on medical claims
among HMO patients already using other common drugs also
cleared by cytochrome P450. Am J Ther. 2003;10:330-340.
9. Stedman CA, Barclay ML. Review article: comparison of the
pharmacokinetics, acid suppression and efficacy of proton pump
inhibitors. Aliment Pharmacol Ther. 2000;14:963-978.
10. Giannini E, Romagnoli P, Fasoli A, et al. Influence of Helicobacter
pylori eradication therapy on 13C aminopyrine breath test: comparison among omeprazole-, lansoprazole-, or pantoprazole-containing
regimens. Am J Gastroenterol. 2000;95:2762-2767.
11. Branch RA. Drugs as indicators of hepatic function.
Hepatology. 1982;2:97-105.
12. Irving CS, Schoeller DA, Nakamura KI, Baker AL, Klein PD.
The aminopyrine breath test as a measure of liver function: a
quantitative description of its metabolic basis in normal subjects.
J Lab Clin Med. 1982;100:356-373.
13. Mion F, Queneau PE, Rousseau M, Brazier JL, Paliard P,
Minaire Y. Aminopyrine breath test: development of a 13C-breath

test for quantitative assessment of liver function in humans.

Hepatogastroenterology. 1995;42:931-938.
14. Kubota T, Chiba K, Ishizaki T. Genotyping of S-mephenytoin
4-hydroxylation in an extended Japanese population. Clin
Pharmacol Ther. 1996;60:661-666.
15. Kodaira C, Sugimoto M, Nishino M, et al. Effect of MDR1
C3435T polymorphism on lansoprazole in healthy Japanese subjects. Eur J Clin Pharmacol. 2009;65:593-600.
16. Ishizaki T, Chiba K, Manabe K, et al. Comparison of the interaction potential of a new proton pump inhibitor, E3810, versus
omeprazole with diazepam in extensive and poor metabolizers of
S-mephenytoin 4-hydroxylation. Clin Pharmacol Ther. 1995;58:
155-164.
17. Ho PM, Maddox TM, Wang L, et al. Risk of adverse outcomes
associated with concomitant use of clopidogrel and proton pump
inhibitors following acute coronary syndrome. JAMA. 2009;
301:937-944.
18. Chen BL, Chen Y, Tu JH, et al. Clopidogrel inhibits CYP2C19dependent hydroxylation of omeprazole related to CYP2C19
genetic polymorphisms. J Clin Pharmacol. 2009;49:574-581.
19. Schneider JF, Schoeller DA, Nemchausky B, Boyer JL, Klein P.
Validation of 13CO2 breath analysis as a measurement of demethylation of stable isotope labeled aminopyrine in man. Clin Chim
Acta. 1978;84:153-162.
20. Fasoli A, Giannini E, Botta F, et al. 13CO2 excretion in
breath of normal subjects and cirrhotic patients after
13
C-aminopyrine oral load: comparison with MEGX test in functional differentiation between chronic hepatitis and liver cirrhosis. Hepatogastroenterology. 2000;47:234-238.
21. Giannini E, Fasoli A, Chiarbonello B, et al. 13C-aminopyrine
breath test to evaluate severity of disease in patients with chronic
hepatitis C virus infection. Aliment Pharmacol Ther. 2002;16:
717-725.
22. McColl KE, Kennerley P. Proton pump inhibitorsdifferences
emerge in hepatic metabolism. Dig Liver Dis. 2002;34:461-467.
23. Ishizaki T, Horai Y. Review article: cytochrome P450 and the
metabolism of proton pump inhibitorsemphasis on rabeprazole. Aliment Pharmacol Ther. 1999;13(suppl 3):27-36.
24. Giannini EG, Malfatti F, Botta F, et al. Influence of 1-week
Helicobacter pylori eradication therapy with rabeprazole, clarithromycin, and metronidazole on 13C-aminopyrine breath test.
Dig Dis Sci. 2005;50:1207-1213.
25. Giannini EG, Savarino V, Testa R. Monitoring cytochrome
P-450 activity during rabeprazole treatment in patients with gastroesophageal reflux disease. Dig Dis Sci. 2006;51:1602-1606.
26. Henry DA, Somerville KW, Kitchingman G, Langman MJ.
Omeprazole: effects on oxidative drug metabolism. Br J Clin
Pharmacol. 1984;18:195-200.
27. Diaz D, Fabre I, Daujat M, et al. Omeprazole is an aryl hydrocarbon-like inducer of human hepatic cytochrome P450.
Gastroenterology. 1990;99:737-747.
28. Rost KL, Brosicke H, Brockmoller J, Scheffler M, Helge H,
Roots I. Increase of cytochrome P450IA2 activity by omeprazole:
evidence by the 13C-[N-3-methyl]-caffeine breath test in poor and
extensive metabolizers of S-mephenytoin. Clin Pharmacol Ther.
1992;52:170-180.
29. Rost KL, Brosicke H, Heinemeyer G, Roots I. Specific and
dose-dependent enzyme induction by omeprazole in human
beings. Hepatology. 1994;20:1204-1212.

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