Pharmacokinetics and tolerability of oral iloprost in thromboangiitis obliterans patients.

OBJECTIVE: Iloprost is a potent PGI2 mimetic, which has been shown to be therapeutically effective in several vascular disorders. Due to its rapid clearance from the central compartment, iloprost is administered mainly by i.v. infusion, which limits its use to hospitalized patients. In order to improve pharmacotherapeutic use of this PGI2 mimetic, an oral extended-release (ER) dosage form has been developed, which should mimic plasma level profiles as observed after i.v. infusion and serve as a therapeutic equivalent.
METHODS: This trial was performed to investigate the tolerability and pharmacokinetics of iloprost administered perorally, compared with i.v. infusion, in 12 patients suffering from thromboangiitis obliterans (TAO). A dose titration was carried out for 1 week with i.v. iloprost, followed by a p.o. titration and treatment phase of 3 weeks' duration. Pharmacokinetics was investigated at the individually tolerated dose levels; i.e., on days 5-7 (i.v. infusion at 2, 2.5 and 3 ng.kg-1.min-1), and twice during p.o. treatment after b.i.d. administration of 50, 100, 150, 200 or 300 micrograms.
RESULTS: Individual tolerability of iloprost varied: 7 patients out of 12 tolerated the maximum i.v. dose of 3 ng.kg-1.min-1; six tolerated the maximum oral dose of 600 micrograms. No patients withdrew from the study due to adverse events. Flush and headache were the most common adverse events and seemed to be related to the study drug. After i.v. infusion of iloprost, dose-normalized (3 ng.kg-1.min-1), steady-state plasma levels were 260 pg.ml-1. Terminal half-life was 0.57 h. Total clearance ranged from 8 to 17 ml.min-1.kg-1. Peroral administration of the ER formulation resulted in dose-dependent Cmax and AUC values. AUC values of the first and second daily dose interval, i.e., 0-5 h and 5-11 h after first dosing, were almost identical. Absolute bioavailability was 24%, with the exception of two patients who tolerated only 50 micrograms b.i.d. and exhibited a bioavailability of approx. 60%. The AUC values observed in weeks 2 and 4 were identical, demonstrating low day-to-day variability of iloprost plasma level profiles in TAO patients.
CONCLUSION: Based upon pharmacokinetic data, the ER formulation provides an equivalent to the i.v. infusion of iloprost and broadens the range of therapy to nonhospitalized patients. The availability of capsules with 50 and 100 micrograms iloprost enables individual dose titration and pharmacotherapy. Beneficial effects, as observed with i.v. iloprost in TAO patients, should therefore be achievable by peroral pharmacotherapy using the new ER formulation.