Objective: The metabolism- and transporter-based drug-drug interactions (DDIs) between mycophenolate mofetil (MMF) and co-administered medications may be key factors for the high individual variability in MMF exposure. This study systematically assessed the influence of co-medications on the mycophenolic acid (MPA) pharmacokinetic (PK) process in vitro, particularly to provide mechanistic evidence of the metabolic interaction among steroids, cyclosporine (CsA), and MMF.Methods: Based on a previous study, we hypothesized that there are three main DDI pathways affecting MMF PK in vivo. A human hepatocyte induction study, transporter substrate/inhibition study using human embryonic kidney 293 cells, and multidrug resistance-associated protein 2 (MRP2) substrate/inhibition study using vesicle membrane were conducted to assess the mechanistic evidence of the metabolic interaction in triple therapies. The potential DDI risks associated with seven medications commonly co-administered with MMF in clinical practice were further evaluated.Results: The in vitro results suggested that prednisolone, the active metabolite of prednisone, induces the enzymatic activity of uridine 5′-diphospho-glucuronosyltransferase (UGT), particularly the UGT1A9 and UGT2B7 isoforms, resulting in increased metabolism of MPA to MPA glucuronide (MPAG). This induction potential was not observed in CsA-treated human hepatocytes. CsA inhibits organic anion-transporting polypeptide (OATP) 1B1- and OATP1B3-mediated MPAG. Prednisolone and CsA showed no inhibitory effect on MRP2-mediated MPAG efflux. Salvia miltiorrhiza significantly inhibited organic anion-transporting polypeptide and OAT 3 activities, suggesting that it affects the hepatic uptake and renal excretion of MPAG, causing increased MPAG exposure in vivo.Conclusion: These identified factors may contribute to the high inter-individual variability in MMF exposure and facilitate further development of mechanistic MMF PK models and individualized therapies.

Radix Angelicae dahuricae, containing coumarins, which might affect cytochrome P450 enzyme (CYP450) activity, has been co-administered with ligustrazine, a substrate of CYP450s, for the clinical treatment of migraine. However, whether a pharmacokinetic-based synergy exists between Radix Angelicae dahuricae and ligustrazine is still unknown. In this study, the total coumarin extract (TCE) of Radix Angelicae dahuricae (50 mg/kg, orally) reinforced the anti-migraine activity of ligustrazine by declining head scratching, plasma calcitonin gene-related peptide, and serum nitric oxide, as well as increasing plasma endothelin levels in rats (p < 0.05). Moreover, the pharmacokinetic study reflected that TCE potentiated the area under the concentration–time curve of ligustrazine and prolonged its mean retention time in rats (p < 0.05). Besides, the IC₅₀ for TCE, imperatorin and isoimperatorin inhibiting ligustrazine metabolism were 5.0 ± 1.02, 1.35 ± 0.46, 4.81 ± 1.14 µg/mL in human liver microsomes, and 13.69 ± 1.11, 1.19 ± 1.09, 1.69 ± 1.17 µg/mL in rat liver microsomes, respectively. Moreover, imperatorin and isoimperatorin were CYP450s inhibitors with IC₅₀ < 10 µM for CYP1A2, 2C9, 2D6, and 3A4. Therefore, this study concluded that Radix Angelicae dahuricae could increase ligustrazine plasma concentration and then reinforce its pharmacological effect by inhibiting its metabolism through interference with CYP450s. This could be one mechanism for the synergy between Radix Angelicae dahuricae and ligustrazine on migraine treatment.

Theaflavins, benzotropolone compounds formed during black tea processing via catechin condensation, have drawn attention for their potential health benefits and diverse biological effects. This study evaluated the inhibitory effects of four theaflavin monomers—theaflavin-3′-gallate, theaflavin-3,3′-digallate, theaflavin-3-gallate, and theaflavin—on eight CYP450 enzymes using pooled human liver microsomes and specific probe substrates, and seven UGT enzymes using human recombinant UGT enzymes and specific probe substrates. Theaflavin-3′-gallate moderately inhibited CYP1A2-catalyzed phenacetin metabolism and CYP2C8-mediated amodiaquine metabolism, with IC₅₀ values of 8.67 μM and 10–20 μM, respectively. Theaflavin-3,3′-digallate exhibited similar effects. Both compounds showed negligible inhibition with other CYP enzymes. In UGT assays, theaflavin-3′-gallate and theaflavin-3,3′-digallate moderately inhibited UGT1A1- and UGT1A3-mediated beta-estradiol glucuronidation (IC₅₀: 1.40–5.22 μM), with weak or no effects on other UGT enzymes. Molecular docking revealed that CYP1A2-theaflavin-3′-gallate and CYP2C8-theaflavin-3,3′-digallate interactions were non-competitive, primarily mediated by hydrogen bonding and π-interactions. UGT1A1-theaflavin interactions suggested non-competitive inhibition, while UGT1A3-theaflavin interactions indicated competitive inhibition. Other enzyme-theaflavin interactions exhibited minimal binding energy differences, implying mixed-type inhibition. These findings highlight the selective inhibitory effects of theaflavins on specific hepatic enzymes, with potential implications for nutrient interactions, particularly for nutrients metabolized by CYP1A2, CYP2C8, UGT1A1, and UGT1A3. Further research is needed to explore the in vivo relevance and assess the dietary implications of theaflavin-rich black tea in nutrition and metabolism.