Influence of CYP2D6 activity on the disposition and cardiovascular toxicity of the antidepressant agent venlafaxine in humans

According to in-vitro studies with microsomes from human livers and from yeast expression systems with high CYP2D6 activity, the major oxidation pathway of venlafaxine is catalysed by CYP2D6. In this study, we investigated the role of the CYP2D6 polymorphism and the effects of low-dose quinidine, a selective inhibitor of, CYP2D6, on the disposition of venlafaxine. Fourteen healthy men, eight with the extensive metabolizer and six with the poor metabolizer phenotype were administered venlafaxine hydrochloride 18.75 mg orally every 12 h for 48 h on two occasions (1 week apart); once alone and once during the concomitant administration of quinidine sulfate 100 mg every 12 h. Blood and urine samples were collected under steady-state conditions over one dosing interval (12 h). When venlafaxine was administered alone, the oral clearance of venlafaxine was more than fourfold less in poor metabolizers compared to extensive metabolizers (P < 0.05). This was mainly due to a decreased capability of poor metabolizers to form O-desmethylated metabolites at the position 4 of the aromatic moiety. In extensive metabolizers, quinidine decreased venlafaxine oral clearance from 100 +/- 62 l/h to 17 +/- 5 l/h (mean +/- SD; P < 0.05) without any effects on renal clearance (4 +/- 1 l/h during venlafaxine alone and 4 +/- 1 l/h during venlafaxine plus quinidine). In these individuals, the sequential metabolism of venlafaxine to O-desmethylvenlafaxine and to N,O-didesmethylvenlafaxine was inhibited by quinidine coadministration so that metabolic clearances to O-desmethylated metabolites decreased from 43 +/- 32 l/h to 2 +/- 1 l/h (P < 0.05). In poor metabolizers, coadministration of quinidine did not cause significant changes in oral clearance and partial metabolic clearances of venlafaxine to its various metabolites. Decreased CYP2D6 activity could also be associated with cardiovascular toxicity as observed in four patients during treatment with the drug. Thus, genetically determined or pharmacologically altered CYP2D6 activity represents a major determinant of venlafaxine disposition in humans.