Refined prediction of pharmacokinetic kratom-drug interactions: Time-dependent inhibition considerations

Abstract

Preparations from the leaves of the kratom plant (Mitragyna speciosa) are consumed for their opioid-like effects. Several deaths have been associated with kratom used concomitantly with some drugs. Pharmacokinetic interactions are potential underlying mechanisms of these fatalities. Accumulating in vitro evidence has demonstrated select kratom alkaloids, including the abundant indole alkaloid mitragynine, as reversible inhibitors of several cytochromes P450 (CYPs). The objective of this work was to refine the mechanistic understanding of potential kratom-drug interactions by considering both reversible and time-dependent inhibition (TDI) of CYPs in the liver and intestine. Mitragynine was tested against CYP2C9 (diclofenac 49-hydrox-ylation), CYP2D6 (dextromethorphan O-demethylation), and CYP3A (midazolam 19-hydroxylation) activities in human liver microsomes (HLMs) and CYP3A activity in human intestinal microsomes (HIMs). Comparing the absence to presence of NADPH during preincubation of mitragynine with HLMs or HIMs, an ∼7-fold leftward shift in IC50 (∼20 to 3 mM) toward CYP3A resulted, prompting determination of TDI parameters (HLMs: KI, 4.1 6 0.9 mM; kinact, 0.068 6 0.01 min21; HIMs: KI, 4.2 6 2.5 mM; kinact, 0.079 6 0.02 min21). Mitragynine caused no leftward shift in IC50 toward CYP2C9 (∼40 mM) and CYP2D6 (∼1 mM) but was a strong competitive inhibitor of CYP2D6 (Ki, 1.17 6 0.07 mM). Using a recommended mechanistic static model, mitragynine (2-g kratom dose) was predicted to increase dextromethorphan and midazolam area under the plasma concentration-time curve by 1.06- and 5.69-fold, respectively. The predicted midazolam area under the plasma concentration-time curve ratio exceeded the recommended cutoff (1.25), which would have been missed if TDI was not considered.