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Antimicrobial Agents and Chemotherapy, December 2005, p. 4903-4910, Vol. 49, No. 12
0066-4804/05/$08.00+0     doi:10.1128/AAC.49.12.4903-4910.2005
Copyright © 2005, American Society for Microbiology. All Rights Reserved.

Interaction of Ritonavir-Boosted Tipranavir with Loperamide Does Not Result in Loperamide-Associated Neurologic Side Effects in Healthy Volunteers

Geoffrey Mukwaya,^1* Thomas MacGregor,¹ David Hoelscher,² Thomas Heming,^3, Daniel Legg,¹ Kelli Kavanaugh,¹ Phillip Johnson,¹ John P. Sabo,¹ and Scott McCallister^1,

Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut,¹ PPD Development, Austin, Texas,² University of Texas, Houston, Texas³

Received 27 April 2005/ Returned for modification 15 June 2005/ Accepted 16 August 2005

Loperamide (LOP) is a peripherally acting opioid receptor agonist used for the management of chronic diarrhea through the reduction of gut motility. The lack of central opioid effects is partly due to the efflux activity of the multidrug resistance transporter P-glycoprotein (P-gp) at the blood-brain barrier. The protease inhibitors are substrates for P-gp and have the potential to cause increased LOP levels in the brain. Because protease inhibitors, including tipranavir (TPV), are often associated with diarrhea, they are commonly used in combination with LOP. The level of respiratory depression, the level of pupil constriction, the pharmacokinetics, and the safety of LOP alone compared with those of LOP-ritonavir (RTV), LOP-TPV, and LOP-TPV-RTV were evaluated in a randomized, open-label, parallel-group study with 24 healthy human immunodeficiency virus type 1-negative adults. Respiratory depression was assessed by determination of the ventilatory response to carbon dioxide. Tipranavir-containing regimens (LOP-TPV and LOP-TPV-RTV) caused decreases in the area under the concentration-time curve from time zero to infinity for LOP (51% and 63% decreases, respectively) and its metabolite (72% and 77% decreases, respectively), whereas RTV caused increases in the levels of exposure of LOP (121% increase) and its metabolite (44% increase). In vitro and in vivo data suggest that TPV is a substrate for and an inducer of P-gp activity. The respiratory response to LOP in combination with TPV and/or RTV was not different from that to LOP alone. There was no evidence that LOP had opioid effects in the central nervous system, as measured indirectly by CO₂ response curves and pupillary response in the presence of TPV and/or RTV.

Present address: Oman Medical College, P.O. Box 391, Postal Code 321, Al Tareef, Sohar, Sultanate of Oman.

Present address: Global Medical Affairs, Pharmaceutical Research Institute, Bristol-Myers Squibb Company, P.O. Box 4000, Princeton, NJ 08540.

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