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Purpose: Higher drug concentrations in complex clinical scenarios in which multiple factors such as drug-drug interactions (DDIs) and comorbidities are simultaneously present are not necessarily rationalized in prospective clinical studies. Physiologically based pharmacokinetic (PBPK) modeling and simulation of the anti-arrhythmic drug flecainide, as an example, were utilized to quantitatively rationalize the higher flecainide concentration in a complex clinical case involving end-stage renal disease (ESRD), cirrhosis, and the co-administration of mexiletine, a CYP1A2 inhibitor., Methods: The developed flecainide PBPK model was used to evaluate the DDI effect (as measured by AUC ratio before and after inhibition) of mexiletine and the combined disease effects of ESRD and cirrhosis on flecainide exposure., Results: The predicted DDI effect of mexiletine was negligible or weak in anuric hemodialysis with cirrhosis population (mean [5th/95th percentiles], 1.23 [0.97-1.67]), although it was negligible in healthy volunteers (1.03 [1.02-1.05]). The predicted flecainide concentrations after multiple flecainide doses (50 mg BID) in the anuric hemodialysis with cirrhosis population were comparable with the observed value (3602 ng/mL), which fell between the predicted concentrations in the absence and presence of mexiletine (3043 [718-8499] and 5914 [880-20,624] ng/mL, respectively)., Conclusions: The PBPK simulation proposed a likely explanation that the observed higher flecainide concentration could be attributed to the combined effects of ESRD, cirrhosis, and a potential DDI with mexiletine. This approach provides quantitative insight into theoretically conceivable extremes in drug exposure occurring in complex clinical situations even if uncommon.

Objective: We examined the effect of gender-associated differences in pharmacokinetics on the anti-arrhythmic effects of flecainide in Japanese patients with supraventricular tachyarrhythmia and in healthy subjects., Methods: The study population comprised 72 outpatients (52 males and 20 females) treated with oral flecainide for supraventricular tachyarrhythmias. Serum flecainide concentrations were determined by use of high-performance liquid chromatography. The anti-arrhythmic efficacy of flecainide was assessed for at least 2 months through evaluation of symptomatology, electrocardiograms, and Holter monitoring. Pharmacokinetics of flecainide after a single 50-mg dose was examined in 14 healthy subjects (7 males and 7 females)., Results: The daily dose of flecainide did not differ between males and females (2.87 +/- 0.68 versus 2.92 +/- 0.90 mg/kg). The serum flecainide concentration was significantly lower in males than in females (315 +/- 151 versus 408 +/- 184 ng/mL, P < 0.05). Clinically relevant efficacy of flecainide was achieved significantly (P < 0.05) less often in male patients (31 of 52; 60%) than in female patients (19 of 20; 95%). We confirmed that nonrenal clearance of flecainide among healthy subjects was significantly higher in males than in females (0.77 +/- 0.16 versus 0.57 +/- 0.06 L h(-1) kg(-1), P < 0.05)., Conclusions: Our results suggest that the anti-arrhythmic efficacy of flecainide differed between males and females because of gender-associated differences in pharmacokinetics.

Objective: To examine the effect of CYP2D6 genotype on the pharmacokinetics of flecainide, we conducted a population pharmacokinetic analysis of the data collected during routine therapeutic drug monitoring of Japanese patients with supraventricular tachyarrhythmia., Methods: Population analysis was performed on retrospective data from 58 patients with normal kidney and liver function treated with oral flecainide for supraventricular tachyarrhythmia. Serum concentrations of flecainide were determined by high-performance liquid chromatography. CYP2D6 genotyping for extensive metabolizer (EM), intermediate metabolizer (IM) and poor metabolizer (PM) alleles was conducted by allele-specific polymerase chain reaction (PCR) and stepdown PCR. WinNonMix was used to estimate oral clearance (CL/F) of flecainide with a one-compartment model for first-order absorption., Results: Body weight, age, sex, serum creatinine concentration (Scr), and CYP2D6 genotype influenced flecainide pharmacokinetics. The CL/F was affected by age (30% reduction in > or =70 years old) and sex (24% reduction in females). The ratios of CL/F for the five CYP2D6 genotypes were: 1.00 (EM/EM), 0.89 (EM/IM), 0.84 (EM/PM), 0.79 (IM/IM), 0.73 (IM/PM). A model including these five covariates reduced the interpatient variability of CL/F from 32.9% (base model) to 17.8%. Using a Bayesian method we estimated that the CL/F in IMs was significantly lower than in homozygous EMs (0.25+/-0.05 l h(-1) kg(-1) vs. 0.37+/-0.08 l h(-1) kg(-1), P<0.05) among male patients under 70 years old., Conclusions: CYP2D6 genotype, even in IMs, as well as body weight, age, sex, and Scr influence flecainide pharmacokinetics in Japanese patients with supraventricular tachyarrhythmia.

Data on the absolute bioavailability of flecainide are controversial. We have investigated whether differences in metabolic clearances and/or the absorption profile might be responsible for the variability in its absolute bioavailability. Six subjects with a wide range of flecainide metabolic clearances (85-407 ml.min-1) simultaneously received the drug by the IV and oral routes; the oral dose was labelled with deuterium. Besides estimation of absolute bioavailability, this design permitted assessment of metabolic clearance after IV and oral administration, and absorption could be assessed from the urinary excretion of labelled and unlabelled drug and metabolites. The absolute bioavailability of flecainide ranged from 79.9 to 101.1% (mean 93.6%). The absorption was 86.1 to 101.3% (mean 93.2%). The data indicate that the variable bioavailability of flecainide is due both to metabolism and absorption. The study highlights the potential of stable isotope technique in the investigation of such issues.

The pharmacokinetics of flecainide has been studied in 12 patients with ventricular arrhythmias, both after single administration and during chronic treatment. Both the half-life and the AUC were significantly increased during chronic treatment. This suggests that the kinetics of flecainide might be non-linear also in patients with normal kidney and liver function. The increase in plasma flecainide levels during chronic treatment could not be predicted, so close monitoring of its plasma levels is advisable.

In order to evaluate the influence of urinary flow rate at different pH values on the pharmacokinetics of the basic antiarrhythmic drug flecainide 7 healthy men received 50 mg flecainide under 4 different conditions: 1. acidic urine (pH 5) and a high fluid load (125 ml.h-1) 2. acidic urine (pH 5) and a low fluid load (25 ml.h-1) 3. alkaline urine (pH 8) and a high fluid load (125 ml.h-1) 4. alkaline urine (pH 8) and a low fluid load (25 ml.h-1) At acidic pH the half-life, the amount of unchanged drug in the urine (Ae), renal clearance (CLR) and area under the curve (AUC) were independent of the fluid load. At alkaline pH Ae (5.8 vs 2.6 mg) and CLR (73 vs 33 ml.min-1) were significantly affected by fluid load (high vs low), whereas half-life and AUC were not different (15.7 vs 16.0 h, 1480 vs 1540 ng.ml-1.h). When comparing acidic and alkaline urinary pH conditions, half-life, Ae, CLR, and AUC were different. For a high fluid load the values at acidic vs alkaline pH were half-life 10.0 vs 15.7 h; Ae 15.9 vs 5.8 mg; CLR 288 vs 73 ml.min-1; AUC 976 vs 1480 ng.ml-1.h. For a low fluid load the corresponding values at acidic vs alkaline pH were half-life 10.1 vs 16.0 h; Ae 15.9 vs 2.6 mg; CLR 267 vs 33 ml.min-1; AUC 1045 vs 1540 ng.ml-1.h. It is concluded that urinary pH affects flecainide pharmacokinetics independently of urinary flow rate, and that a high flow enhances the elimination of flecainide only with an alkaline urine. This effect of flow rate does not appear to be of clinical relevance.

An intravenous infusion regimen for flecainide was studied in 12 patients. Therapeutic drug levels were rapidly established and maintained throughout the 48-h infusion period. Two patients were withdrawn because of possible drug related problems, but in general the regimen seemed both effective and well tolerated.

We have studied the pharmacokinetics of flecainide after the oral administration of 100 mg to 8 patients without renal impairment and 8 patients with mild to moderate renal failure. Both groups gave comparable results with respect to the peak plasma concentrations and the time to peak. There was a significant correlation between renal flecainide clearance and endogenous creatinine clearance. The elimination half-time in the patients with impaired renal function was significantly longer (19.9, SD 9.9 h) than that in the patients with normal renal function (11.5, SD 4.2 h), but the variability in the elimination half-time in renal failure could not be explained on the basis of the available results.