Impact of Acute and Chronic Inflammation on Cytochromes P450 Activity Measured With Dried Blood Spot

Study Overview
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Brief Summary
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Cytochromes P450, main enzymes of drug metabolism, play a prominent role in the first-pass metabolism of oral substances. Inter-individual variability in their activity due to genetic and environmental factors has been observed and may be associated with adverse therapeutic outcomes (ineffectiveness or toxicity). The inflammation, whether acute or chronic, can theoretically modulate the pharmacokinetics of drugs by modulating enzyme activity. Indeed, in vitro data and animal models, as well as more limited data in humans, indicate a down-regulation of CYP in the context of inflammation. The cocktail approach developed and validated in Geneva (cocktail Geneva) measures the activity of several CYP simultaneously using micro-doses of probe drugs and facilitating sampling (10uL capillary blood) on a dried blood spot. We intend to measure the activity of CYP in an acute inflammation model (hip surgery and SARS-CoV-2 infection) and chronic inflammation (rheumatoid arthritis, RA). The effect of the biological agent tocilizumab (anti IL-6 receptor) in a treated patient subgroup (patients treated regardless of our study) will be measured after 3 months of treatment. The main objective is to determine if interleukin 6 levels are correlated with the activity of CYP450 in patients with acute (orthopedic surgery - hip or SARS-CoV-2 infection) or chronic inflammation (RA). Secondary objectives are: To correlate CYPs activities with the levels of other inflammatory markers (CRP, TNF-α, IL-1β, IFN-γ); To assess correlation between markers of inflammation, CYP activities and the intensity of fatigue and pain; To assess if tocilizumab reverse CYP activity in patients with RA after 3 months treatment; To assess if SARS-CoV-2 infection modify pharmacokinetic parameters of concomitant medications which are CYPs substrates

Official Title
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Impact of Acute and Chronic Inflammation on Cytochromes P450 Activity Measured With Dried Blood Spot

Conditions
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Inflammation

Intervention / Treatment
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* Diagnostic Test: CYP phenotyping


Participation Criteria
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Eligibility Criteria
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--> Inclusion Criteria: For hip surgery and chronic inflammation groups Male and female patients diagnosed with rheumatoid arthritis or undergoing an elective hip surgery Age > 18 years old Understanding of French language and ability to give a written inform consent For SARS-CoV-2 infection group Male and female patients diagnosed with SARS-CoV-2 infection (positive RT-PCR) and CRP > 30 mg/L Age > 18 years old Understanding of French language and ability to give a written inform consent --> Exclusion Criteria: For hip surgery and chronic inflammation groups Pregnant or lactating females Severe cardiac failure, severe edema or ascites Severe COPD or pulmonary embolism requiring oxygen Uncontrolled infection Active cancer HIV infection Renal impairment (defined as serum creatinine concentrations > 1.5 x ULN) Hepatic impairment (alteration of hepatic tests AST, ALT, bilirubin, GGT >2 x ULN) Inability to give blood samples Sensitivity to any of the drugs used Intake of drugs altering CYPs activity (based on [1]) except for tocilizumab For SARS-CoV-2 infection group Pregnant or lactating females Hospitalized in intensive care unit at time of inclusion Hospitalized in intermediate care unit at time of inclusion Active cancer HIV infection Renal impairment (glomerular filtration rate < 30 mL/min/1.73m2) Hepatic impairment (Child-Pugh score B and C) Inability to give blood samples Sensitivity to any of the drugs used

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Patient with acute inflammation (surgery)<br>patients undergoing hip surgery | Diagnostic Test: CYP phenotyping<br>* Phenotyping using a simplified version of the Geneva cocktail<br>|
| Patient with chronic inflammation<br>patients with rheumatoid arthritis | Diagnostic Test: CYP phenotyping<br>* Phenotyping using a simplified version of the Geneva cocktail<br>|
| Patient with acute inflammation (SARS-CoV-2 infection)<br>patients with SARS-CoV-2 infection | Diagnostic Test: CYP phenotyping<br>* Phenotyping using a simplified version of the Geneva cocktail<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Evaluate the impact of IL6 levels on the activity of CYPs in patients with acute (post orthopaedic surgery -hip or post SARS-CoV-2 infection) and chronic (rheumatoid arthritis) inflammation. | The phenotyping probe drugs used in this study will be given as 2 capsules: one capsule of Omeprazole 10 mg and one capsule containing the remaining probe 'cocktail' drugs (caffeine 50 mg, flurbiprofen 10 mg, dextromethorphan 10 mg, midazolam 1 mg, bupropion 20 mg). The enzymatic activities of the following CYP will be assessed by specific metabolite/probe single point concentration ratios (metabolic ratios-MR) in capillary blood: CYP1A2 CYP2B6 CYP2C9 CYP2C19 CYP2D6 CYP3A4 | 1 week | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Evaluate the correlation between the activity of CYPs and CRP levels | The routine concentration of the inflammatory marker C-reactive protein (CRP) will be measured in blood | 1 week or 3 months | 
| Evaluate the correlation between the activity of CYPs and TNF-α levels | TNF-α blood concentrations will be measured by using the Fluorokine MAP Cytokine Multiplex Elisa. | 1 week or 3 months | 
| Evaluate the correlation between the activity of CYPs and IL-1β levels | IL-1β blood concentrations will be measured by using the Fluorokine MAP Cytokine Multiplex Elisa. | 1 week | 
| Evaluate the correlation between the activity of CYPs and IFN-γ levels | IFN-γ blood concentrations will be measured by using the Fluorokine MAP Cytokine Multiplex Elisa. | 1 week | 
| Assess if tocilizumab reverse the activity of CYP in patients with RA after 3 months of treatment | Comparison of CYP function before and 3 months after the beginning of the Tocilizumab treatment. | 3 months | 
| Assess if SARS-CoV-2 infection modify pharmacokinetic parameters of concomitant medications which are CYPs substrates | Comparison of plasma concentrations of CYPs substrates, when COVID-19 patients received any CYPs substrates | 3 months | 
| Evaluate the correlation between inflammatory markers, CYP function and intensity of fatigue (MFI) and pain (NRS) | Function and intensity of fatigue will be measured with the validated French version of the Multidimensional Fatigue Inventory; pain will be measured with the numeric rating scale (NRS) 0 to 10 (0 = no pain and 10 = worst pain imaginable). | 1 week | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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cytochromes P450, chronic inflammation, genotyping, phenotyping, acute inflammation, rheumatoid arthritis, surgery, COVID-19, SARS-CoV-2 infection