Study On Interaction Profile And Mechanism Between Danhong Injection And Ceftriaxone

Accompanied by the development of aging,comorbidities and multi-morbidities have become common seen.Multidrug therapy has become the important mode of clinical treatment.The traditional Chinese medicine inj ections,as being the focus of the Chinese Administration of Food and Drug Administration,have been widely used in clinic.While the situation of clinical combination of traditional Chinese medicine injections is complex.However,the research foundation of drug-drug interactions is weak.As a result,unknown benefits or risks will be brought to such concomitant use of drugs in clinic.Danhong Inj ection is a commonly used traditional Chinese medicine inj ection for promoting blood circulation and removing blood stasis.It has been recommended by many experts on cardiovascular and cerebrovascular diseases and has already formed a consensus among Chinese experts on clinical application.However,there are relatively few studies on the concomitant use of Danhong Injection.Based on the actual situation of infection combined with cardiovascular and cerebrovascular disease in clinic,Danhong injection and ceftriaxone were selected as the representative combination of high frequency to be investigated,according to the previous work of clinical literature research and data mining.The characteristics and mechanisms between Danhong injection and ceftriaxone were investigated from the perspective of pharmacokinetics and pharmacodynamics interactions,so as to discover the potential benefits and risks of such combination in clinic,and provide data support for improving safety risk warning system of Danhong injection in the future,and also provide research basis for the evaluation of interactions between traditional Chinese medicine inj ection and antibiotics.1.Literature studyLiterature study was conducted and summarized on the clinical progress of combined use of traditional Chinese medicine injection and antimicrobial drugs.The clinical reports of Danhong injection and cephalosporins combination and with their respective drug interactions were aslo summarized,so as to provide the basis for clinical data mining and experiments of herb-drug interactions,and discovering characteristics and possible mechanisms.1.1 Current situation of clinical combination of traditional Chinese medicine injection and antibioticsThe traditional Chinese medicine injection for heat-clearing and detoxifying are commonly used in combination with antibiotics,which can synergize in the treatment of respiratory tract infections and pulmonary infections caused by various bacteria.However,there are few reports on the interactions betweem the combinations.It is commonly reported there was incompatibility of traditional Chinese medicine injections with antibiotics,but there are few reports on the clinical application of the combination.1.2 Clinical analysis of Danhong injection combined with cephalosporins1.2.1 At present,there are only a few reports about the incompatibility of Danhong injection and cephalosporins,but no literature on the herb-drug interactions between Danhong injection and cephalosporin had been found.Danhong injection and cephalosporins have their own drug-drug interactions research bases respectively.The herb-drug interactions research of Danhong injection mainly focuses on metabolic pharmacokinetic interactions.Its major phenolic acid components,which usually have high plasma protein binding rate,can significantly inhibit nine CYP 450 subtypes of human liver microsomes and corresponding subtypes of rat liver microsomes in vitro.Danhong injection can significantly inhibit the renal organic anion transporters OAT1,OAT3 and liver organic anion transporters OATP1B1 and OATP1B3.1.2.2 Pharmacokinetic interactions of cephalosporins are mainly studied in plasma protein and transporters:ceftriaxone is the representative cephalosporin with high protein binding rate.The influx transporters related to cephalosporins are mainly renal organic anion transporters OAT1 and OAT3,liver organic anion transporters OATP1B1 and OATP1B3,and intestinal oligopeptide transporters PEPT1 and PEPT2.The main efflux transporters are MRP2,MRP4 and BCRP.2.Data mining on the drug combination rules of Danhong injection based on clinical data7713 cases of patients were selected in the Affiliated Hospital of Nanjing University of Chinese Medicine during 2013 and 2015.A database was established included a total of 73 653 records of the drug combinations of Danhong Injection.Data mining was carried out according to the demographic characteristics,main diagnosis and combined use of Danhong Injection,in order to provide the clinical evidence of drug interactions experiments.2.1 The association rules of the drug combinations of Danhong injection based on clinic data mining2.1.1 75.82%of the patients used Danhong injection were aged above 60 years old.The main clinical diagnoses were hypertension(72.29%),cerebral infarction(58.25%),coronary heart disease(40.94%)and diabetes mellitus(27.28%).The four diagnoses have close relations.More than 90.22%of Danhong users had complications.2.1.2 66729 effective medications of 6935 patients with four major diagnostic diseases were selected to analyze the rules of the combination of Danhong injection according to different years,genders and ages.The frequency of Danhong injection combined with antiplatelet drugs,lipid-regulating drugs,drugs for cerebral blood vessel diseases and proton pump inhibitors increased by year.Women patients were more likely to use drugs for cardiovascular diseases(minimum support≥10%,minimum confidence)90%,minimum lift 1.00),while men were more likely to use drugs for cerebrovascular diseases(minimum support ≥15%,minimum confidence)90%,minimum lift 1.00).Antiplatelet drugs and agents for cerebrovascular diseases were commonly combined with Danhong inj ection in patients younger than 80 years old,while the cardiovascular drugs and diuretics were more commonly used in the patients more than 80 years old(minimum support≥20%,minimum confidence≥65%,minimum lift 1.00).2.2 The rule analysis of Danhong injection and antibiotics based on clinical data mining2.2.1 86.27%of the patients were over 60 years old.The main complications were pulmonary infection(25.05%),urinary tract infection(9.19%)and gastroenteritis(8.90%).The most frequent and closely related diagnosis was hypertension and pulmonary infection(25.05%).Cephalosporins(68.77%),quinolones(32.01%)and penicillins(11.3 1%)were the most frequently used antibiotics in combination with Danhong injection,among which ceftriaxone was the most combined with Danhong injection.2.2.2 Based on 1033 ADRs of Danhong injection in Jiangsu ADRs Monitoring Center,the medication of 10 cases were treated with antibiotics,including 8 cases involving cephalosporins.Because of the small sample size of ADRs and the incomplete record of the causes of ADRs in the medical records,it is impossible to judge the correlation between ADRs and antibiotics combined with Danhong injection.It had been found that there was incompatibility between Danhong injection and cephalosporin antibiotics in clinical literatures,and there were common targets in vivo.Therefore,ceftriaxone was chosen as the representative of cephalosporins combined with Danhong inj ection for drug interaction experiments.3.Interactions between Danhong injection and ceftriaxone based on pharmacokinetics study As ceftriaxone is not metabolized in vivo,the pharmacokinetics interaction between Danhong injection and ceftriaxone was studied based on the distribution and excretion process.3.1 Pharmacokinetics profiles were changed on the interactions between Danhong injection and ceftriaxone3.1.1 In the single combination,the effect of ceftriaxone on the process of Danhong injection in vivo was found.A significant decrease in the plasma concentration and exposure of p-coumaric acid and salvianolic acid B were found in the combination(P<0.05).Danhong injection had little effect on the pharmacokinetics of ceftriaxone.3.1.2 In the multi-combination,the effect of Danhong injection on the process of ceftriaxone in vivo was more important.The highest plasma concentration of ceftriaxone decreased after 7 days of repeated combined use.There was no significant difference in the plasma concentration and exposure of phenolic acids in Danhong inj ection.When Danhong inj ection was used for 7 days in advance,then combined with ceftriaxone for the next 7 days,the plasma concentration and exposure of ceftriaxone were significantly reduced.While the plasma concentration and exposure of p-coumaric acid,salvianolic acid D,rosmarinic acid and salvianolic acid B were significantly increased.3.1.3 Both single and multiple combinations could reduce the plasma concentration and exposure of ceftriaxone in old rats,but the decreasing effect of multiple combinations on the process of ceftriaxone tends to be less in vivo.3.2 Ceftriaxone compete binding with human serum albumin with the phenolic acids in Danhong injection3.2.1 The phenolic acids in Danhong injection,protocatechuic aldehyde,p-coumaric acid,salvianolic acid D,rosmarinic acid,lithospermic acid and salvianolic acid B,have medium to high protein binding rates in human plasma.3.2.2 Ultrafiltration assay in vitro showed that high concentration of ceftriaxone competed with phenolic acids to bind human serum albumin(HSA).The results of fluorescence quenching showed that the binding modes of phenolic acid and ceftriaxone with HSA were mainly static quenching.The phenolic acids could significantly reduce the static quenching binding parameters of ceftriaxone,but they may not compete for the same binding site.3.3 Danhong injection could influence the excretion of ceftriaxone3.3.1 The urine excretion and cumulative excretion fraction of ceftriaxone increased in the course of multiple combinations,which may be one of the ways to decrease the plasma concentration of ceftriaxone.The bile excretion of ceftriaxone tends to increase during the combination.3.3.2 The combination of Danhong inj ection and ceftriaxone has a tendency to increase glomerular filtration.Improving glomerular filtration function may be one of the ways to decrease the plasma concentration of ceftriaxone.3.3.3 Compared with ceftriaxone used alone,multiple combinations had no significant effect on the gene and protein expression levels of rOatl and rOat3 influx transporters in rats,nor on the gene expression of the efflux transporters rBcrp and rMrp4,but could significantly increase the gene expression and protein expression level of rMrp2.Danhong inj ection can induce MRP2 gene expression in HEK293 cells,so as to increase ceftriaxone excretion from renal tubular epithelial cells to urine and decrease plasma concentration.3.3.4 The urine excretion of rosmarinic acid and salvianolic acid D was significantly increased by multiple combinations.The reason may be the inhibition of the high concentration of ceftriaxone in hepatic cells on the excretion of rosmarinic acid and salvianolic acid D into bile.So compensatively increases the urine excretion of rosmarinic acid and salvianolic acid D.Clinical significanceThe combined use of ceftriaxone and Danhong injection in adult and old rats can significantly reduce the concentration and exposure of ceftriaxone in vivo.The Cmax and AUC of ceftriaxone were not equivalent to the group used alone.It shows that the combined use can affect the bioequivalence of ceftriaxone.It is suggested that the pharmacokinetics effects of different dosage regimens on ceftriaxone should be further investigated,and the attention should be paid to the plasma concentration monitoring of ceftriaxone in clinic.4.Interactions between Danhong injection and ceftriaxone based on pharmacodynamics studyPharmacodynamics is the end point of drug interaction.Based on the main pharmacodynamics of Danhong inj ection and ceftriaxone,the pharmacodynamic interactions between Danhong inj ection and ceftriaxone were studied.4.1 The combination antibacterial effects of Danhong injection and ceftriaxone in vitroDanhong inj ection showed weak inhibitory effect on Staphylococcus aureus ATCC 23593(MSSA),and no effects on clinical methicillin-resistant S.aureus(MRSA).The combination of Danhong injection with ceftriaxone,cefuroxime and cefepime showed additive and synergistic effects in vitro.4.2 The effects on activating circulation and removing blood stasis and anti-inflammation of multiple combinations4.2.1 The national standard ratio,prolong prothrombin time,thrombin time and activated prothrombin time of the multiple combinations were significantly increased in adult rats,and the level of serum TxB2 was reduced.But it has no significant effects on the anti-platelet function.And it has the tendency to reduce the level of systemic inflammatory factors,but there is no significant difference compared with Danhong injection or ceftriaxone used alone.4.2.2 The multiple combinations could significantly enhance the anti-coagulation,anti-thrombosis and anti-platelet function in old rats,and significantly reduce the level of systemic inflammatory factors,but there were no significant difference compared with Danhong injection or ceftriaxone used alone.Clinical significanceThe combined use can significantly increase the concentration and exposure of phenolic acids in Danhong inj ection in adult rats.The combined use is not equivalent to Cmax and AUC in Danhong injection used alone.Pharmacodynamic results showed that the combined use can enhance the anti-coagulation and anti-thrombotic effects in adult rats.Therefore,attention should be paid to monitoring the coagulation function of patients in clinic.However,the combined use did not significantly affect the anti-coagulation,anti-thrombosis and hemorheology in old rats.