臺灣博碩士論文加值系統

中文摘要
Rabeprazole是屬於氫離子幫浦抑制劑中的一個較新的成分。它的部份代謝路徑是經由CYP2C19這個酵素，同時，thioether-rabeprazole (rabeprazole的代謝物之一)亦被認為是經由CYP2C19代謝。CYP2C19這個酵素在基因控制是有多型性表現的，並且在東方人有較西方人高的變異機率。雖然CYP2C19不是rabeprazole代謝的主要酵素，然而有報告顯示在不同的CYP2C19基因型會表現出對Rabeprazole不同的代謝能力。更有報告顯示，單一劑量給予Rabeprazole在不同的CYP2C19基因型對藥動學參數以及泌酸的抑制程度上有影響。然而，在多劑量給予Rabeprazole後的泌酸的抑制程度是否受CYP2C19基因多型性影響則仍未有定論的現象。另外，報告顯示使用Rabeprazole(20mg, BID) 四天併用clarithromycin 及amoxicillin即能達90%的幽門桿菌殺菌率。而三天Rabeprazole併用clarithromycin 及amoxicillin則發現只有72%殺菌率。
這是一個單一醫學中心，開放性設計的試驗。此試驗欲探討CYP2C19之基因多型性表現在健康人給予rabeprazole單劑量和多劑量後藥動學及藥效學上的影響程度。所有受試者會先決定其個別在CYP2C19之基因型。12名健康志願者被納入此試驗，其中6名為CYP2C19 PMs (poor metabolizers)，另外6名為CYP2C19 homEMs (extensive metabolizers)。試驗之進行是多劑量給予Rabeprazole(20 mg bid)共四天。試驗的第一天，在第一個劑量前半小時，第一個劑量後0.5，1，2，3，4，5，6，7，8，10及12小時的每一個時間點抽取10 ml 的血液。試驗第四天，最後一個劑量之後的0.5，1，2，3，4，5，6，7，8，10，12及24小時的每一個時間點被抽取10 ml 的血液。所抽取的血液樣本將作藥動學(rabeprazole, thioether-rabeprazole血漿濃度)及藥效學的分析(血漿胃泌素)之用。
服用單劑量及多劑量rabeprazole之後，血漿中rabeprazole和thioether-rabeprazole濃度顯著地受到CYP2C19基因型態的影響。血漿胃泌素濃度在此用來反映胃內酸鹼的相對程度。多劑量rabeprazole之後，12小時胃泌素濃度中位數在PMs和homEMs之間有顯著差異，但單劑量則未有顯著差異。顯示多劑量在胃泌素分泌有一延遲增強作用。另外，rabeprazole 和thioether-rabeprazole在濃度對時間曲線下面積並未在多劑量給予rabeprazole之後有增加的現象。這表示多次服用rabeprazole不會有藥物累積的情況。然而，在PMs發現其第四天的12小時胃泌素濃度中位數明顯大於第一天。另一方面亦觀察到在健康人幽門桿菌的感染與否並不會明顯影響胃泌素的分泌。總結前述，rabeprazole 藥物動力學以及其在藥效學上的影響的確受到CYP2C19基因型態的不同而有所影響。可以預期未來基因型分析在超短三合一療程當中對於療效理想化是一項相當有用的工具。

Abstract
Sodium Rabeprazole is a relative new agent in the class of proton pump inhibitors. Rabeprazole is metabolized partially by CYP2C19, and one of its metabolites, thioether-rabeprazole is considered to be metabolized by CYP2C19, too. In addition, CYP2C19 exhibits a genetic polymorphism and there are more PMs in Asians than in Caucasians. Although CYP2C19 is not the major enzyme involved in its metabolism, it has been shown that people with different CYP2C19 genotypes have different abilities to metabolize rabeprazole either after single dose or multiple doses. However, diverse influences of CYP2C19 genotype statuses on pharmacodynamic effect of rabeprazole were observed. Lueth et al. (2001) observed that a four-day triple therapy of rabeprazole (20 mg bid) in combination with clarithromycin and amoxicillin is highly effective in eradication H. pylori. However, Wong et al. (2001) observed that the H. pylori eradication rate of 3-day rabeprazole-based triple therapy is about 72%.
This study was a single center, open-label study. It compared the pharmacokinetic and pharmacodynamic properties of rabeprazole after single and multiple dosing between healthy Taiwanese subjects with different genotypes of CYP2C19. Twelve healthy volunteers including 6 CYP2C19 homEMs and 6 CYP2C19 PMs were enrolled in this study. Multiple dose of rabeprazole (20 mg, b.i.d.) were given to volunteers for 4 days. At day-1, aliquots of 10-ml blood samples were drawn 30 minutes before drug administration and 0.5, 1, 2, 3, 4, 5, 6, 7, 8, 10, 12 hours after the start of oral administration. At day-4, aliquots of 10-ml blood samples were drawn at 0.5, 1, 2, 3, 4, 5, 6, 7, 8, 10, 12, and 24 hours after the seventh dose. Both pharmacokinetic and pharmacodynamic properties were analyzed.
After single and repeated dosing of rabeprazole, the plasma concentration of rabeprazole and its thioether metabolite are significantly dependent on CYP2C19 genotype. Plasma gastrin concentration is used as a surrogate marker of intragastric pH. The 12-hrs median plasma gastrin concentrations after the final dose of rabeprazole are different between PMs and homEMs. Otherwise, AUC for rabeprazole and thioether-rabeprazole do not increase with repeated doses. There is no accumulation effect in administrating of rabeprazole with respect to PK properties. However, 12-hrs median plasma gastrin concentrations at day-4 are significant higher than that at day-1 in PMs but not homEMs. In addition, it is also observed that H. pylori infection doesn’t influence gastrin secretion. In conclusion, the CYP2C19-mediated metabolism and the CYP2C19-related pharmacodynamic effect on plasma gastrin concentrations are significant different between the two genotype groups (PMs vs. homEMs). Prior testing of CYP2C19 genotype statuses may be used to optimize drug dosage and H. pylori eradication rate of ultra-short triple therapy in the future.

TABLE OF CONTENTS
LIST OF FIGURES……………………………………………….………………..III
LIST OF TABLES………………………………………………………………….VI
LIST OF APPENDIXES..…………………………………………………….……..V
ABSTRACT (CHINESE)……………………………………………………….…VII
ABSTRACT (ENGLISH)…………………………………………………..………IX
I. SIGNIFICANCE…………………………………………………………………..1
II. INTRODUCTION………………………………………………………………..4
1. Peptic ulcer disease…………………………….……..……………..…………...4
2. Treatment of H. pylori associated peptic ulcer disease…….……………………7
3. Rabeprazole…………………………..………………………………………....12
a. Physical and chemical properties of rabeprazole…………………………….12
b. Pharmacology of rabeprazole……………………………………………......12
c. Pharmacokinetic profile of rabeprazole……………………….……………...18
4. The correlation of plasma gastrin with intragastric pH and the influences
of Helicobacter pylori on gastrin and acid secretion…………………………...24
5. CYP2C19 polymorphism………………………………………….……………28
III. METHOD…………………………………………………………………….…42
1. Subjects.………………………………………………………………………..42
2. Design………..………………………………………………….…………..…43
3. Experiment method…………………………………………………………….45
a. Genotyping for CYP2C19…..…………………………………..……….…..45
b. Determination of H. pylori infection─13C-UBT………..…………..….……50
c. Determination of rabeprazole and thioether-rabeprazole plasma concentration…………………………………………………………………51
d. Determination of plasma gastrin concentration……..………….…………....52
4. Pharmacokinetic and pharmacodynamic analysis….…………….………..…...54
5. Statistical analysis………..……………………………………………….……55
IV. RESULTS…………………………………………………………………..……61
1. Basic information of subjects……………………………………………..……61
2. Pharmacokinetic parameters of rabeprazole and thioether—rabeprazole….……61
3. Plasma gastrin concentration after rabeprazole dosing………….………..……62
4. The influence of H. pylori in plasma gastrin concentration…………………....64
5. PK and PD correlation……………………………………………….…………65
6. Adverse reaction………………………………………………….……….……65
V. DISSUSSION………………………………………………………………….…77
VI. REFERENCS……………………………………………………………..……87
VII. APPENDICES……………………………………………………………..…111
LIST OF FIGURES
Figure
1-1 The importance of gastric mucus and bicarbonate to the production of the mucus gel layer……………………………………………………………….32
1-2 Anatomically, the stomach is divided into several segments…………………33
1-3 Structural formula of rabeprazole and it’s physicochemical properties……....34
1-4 A parietal cell and the mechanism of acid secretion………………………….35
1-5 Reaction mechanism of four substituted 2-pyridylmethylsulfinyl benzimidazole……………………………………………………………...…36
1-6 Activation of the acid pump in the parietal cell……………………………....37
1-7 Inhibition of the H+/K+ ATPase by proton pump inhibitors (PPIs)………..…38
1-8 Metabolic pathway of rabeprazole……………………………………………39
1-9 Regulation of gastric acid secretion………………………………………..…40
2-1 The flow chart of DNA extraction………………………………………...….56
2-2 The predicted size of the digested DNA fragments for the various genotypes
of CYP2C19…………………………………………………………………58
3-1 RFLP results of CYP2C19M1 genetic polymorphism……………………….70
3-2 RFLP results of CYP2C19M2 genetic polymorphism…………………….…71
3-3 Mean plasma concentration-time data of rabeprazole after the first
and seventh doses of 20 mg rabeprazole (bid) in PMs and homEMs of CYP2C19…………………………………………………………………..72
3-4 Relationship of plasma concentration-time of thioether-rabeprazole after the first and seventh doses of 20 mg rabeprazole (bid) in PMs and Homozygous EMs of CYP2C19…………………………………………………………..73
3-5 Mean plasma concentration-time sata of gastrin after the first and seventh doses of 20 mg rabeprazole (bid) in PMs and homEMs of CYP2C19……..74
3-6 Mean plasma concentration-time data of gastrin after the first and seventh doses of 20 mg rabeprazole (bid) in homEMs of CYP2C19 with and without
H. pylori infection……………………………………………………………75
3-7 Plasma concentration of rabeprazole and gastrin data after the first and seventh dose of 20 mg rabeprazole (bid) in PMs and homEMs of CYP2C19…….…76
LIST OF TABLES
Table
1-1 Frequencies of CYP2C19 allele in various racial groups…………………….41
2-1 The volume of Standard Working Solutions (STD WS) were spiked to make plasma sample concentration as 10, 20, 50, 100, 200, 500, 1000, 2000 and 3000 ng/ml, which construct a standard curve……………………………….59
2-2 The procedure of determination plasma gastrin concentration outline of each tube………………………………………………………………………...…60
3-1 Demographics of healthy volunteers………………………………………….66
3-2 Pharmacokinetic parameters of rabeprazole and thioether-rabeprazole after 20 mg bid dosing at day-1 and day-4 in CYP2C19 poor metabolizers (PMs) and extensive metabolizers (EMs)………………………………………………..67
3-3 Gastrin-time AUC after dosing of rabeprazole at day-1 and day-4 on CYP2C19 poor metabolizers (EMs)……………………………………………………..68
3-4 Comparing of healthy EMs’ gastrin concentration in different H. pylori
condition…………………………………………………………………..…69
4-1 PK and PD effect of rabeprazole in different regimens…………….………..86
LIST OF APPENDICES
Appendix
I Case report form………………………………………………………………..111
I-1 Flow chat of clinical trial…………………………………………………...113
I-2 Screening Table……………………………………………………………..114
I-3 Medication giving record………………………………………………...…115
I-4 Blood drawing record……………………………………………………....116
I-5 Health record………………………………………………………………..117
I-6 Informed consent………………………………………………………..….118
II……………………………………………………………………………………122
III……………………………………………………………………………………125
IV…………………………………………………………………………………....126
V……………………………………………………………………………………..128

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