Plasma concentrations of inhaled budesonide and its effects on plasma cortisol are increased by the cytochrome P4503A4 inhibitor itraconazole

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Abstract
Objective Our objective was to examine the effects of itraconazole on the pharmacokinetics and cortisol‐suppressant activity of budesonide administered by inhalation. Methods In a randomized, double‐blind, 2‐phase crossover study, 10 healthy subjects took 200 mg itraconazole or placebo orally once a day for 5 days. On day 5, 1 hour after the last dose of itraconazole or placebo, 1000 μg budesonide was administered by inhalation. Plasma budesonide and cortisol concentrations were measured up to 23 hours. Results Itraconazole increased the mean total area under the plasma concentration‐time curve of inhaled budesonide 4.2‐fold (range, 1.7‐fold to 9.8‐fold; P < .01) and the peak plasma concentration 1.6‐fold (P < .01) compared with placebo. The mean terminal half‐life of budesonide was prolonged from 1.6 to 6.2 hours (ie, 3.7‐fold; range, 1.5‐fold to 9.3‐fold; P < .001) by itraconazole. The suppression of cortisol production after inhalation of budesonide was significantly increased by itraconazole as compared with placebo, as shown by a 43% reduction in the area under the plasma cortisol concentration‐time curve from 0.5 to 10 hours (P < .001) and a 12% decrease in the cortisol concentration measured 23 hours after administration of budesonide, at 8 am (P < .05). Conclusions Itraconazole markedly increased systemic exposure to inhaled budesonide, probably by inhibiting the cytochrome P4503A4‐mediated metabolism of budesonide during both the first‐pass and the elimination phases. This interaction resulted in enhanced systemic effects of budesonide, as shown by suppression of cortisol production. Long‐term coadministration of budesonide and a potent CYP3A4 inhibitor may be associated with an increased risk of adverse effects of budesonide. Clinical Pharmacology & Therapeutics (2002) 72, 362–369; doi: 10.1067/mcp.2002.127397

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