Eur J Clin Pharmacol (1998) 53: 445±449
PHARMACOKINETICS AND DISPOSITION
K.-M. Kaukonen á K. T. Olkkola á P. J. Neuvonen
Fluconazole but not itraconazole decreases the metabolism
of losartan to E-3174
Received: 4 June 1997 / Accepted in revised form: 10 September 1997
Abstract Objective: Losartan is metabolised to its active
metabolite E-3174 by CYP2C9 and CYP3A4 in vitro.
Itraconazole is an inhibitor of CYP3A4, whereas ¯u-
conazole a€ects CYP2C9 more than CYP3A4. We
wanted to study the possible interaction of these anti-
mycotics with losartan in healthy volunteers.
Methods: A randomised, double-blind, three-phase
crossover study design was used. Eleven healthy volun-
teers ingested orally, once a day for 4 days, either it-
raconazole 200 mg, ¯uconazole (400 mg on day 1 and
200 mg on days 2±4) or placebo (control). On day 4, a
single 50-mg oral dose of losartan was ingested. Plasma
concentrations of losartan, E-3174, itraconazole, hy-
droxy-itraconazole and ¯uconazole were determined
over 24 h. The blood pressure and heart rate were also
recorded over 24 h.
Results: The mean peak plasma concentration (Cmax)
and area under the curve [AUC…0±1†] of E-3174 were
signi®cantly decreased by ¯uconazole to 30% and to
47% of their control values, respectively, and the t1/2
was increased to 167%. Fluconazole caused only a
nonsigni®cant increase (23±41%) in the AUC and t1/2 of
the unchanged losartan. Itraconazole had no signi®cant
e€ect on the pharmacokinetic variables of losartan or
E-3174. The ratio AUC…0±1)E-3174/AUC…0±1†losartan
was 60% smaller during the ¯uconazole than during the
placebo and itraconazole phases. No clinically signi®-
cant changes in the e€ects of losartan on blood pressure
and heart rate were observed between ¯uconazole,
itraconazole and placebo phases.
Conclusion: Fluconazole but not itraconazole interacts
with losartan by inhibiting its metabolism to the active
metabolite E-3174. This implicates that, in man,
CYP2C9 is a major enzyme for the formation of E-3174
K.-M. Kaukonen (&) á K.T. Olkkola á P.J. Neuvonen
Department of Clinical Pharmacology,
University of Helsinki, Haartmaninkatu 4,
FIN-00290 Helsinki, Finland
Tel.: +358 9 471 4036; Fax: +358 9 471 4039;
e-mail: maija.jalava@helsinki.®
Ó Springer-Verlag 1998
from losartan. The clinical signi®cance of the ¯ucona-
zole±losartan interaction is unclear, but the possibility of
a decreased therapeutic e€ect of losartan should be kept
in mind.
Key words Fluconazole, Losartan
Introduction
Losartan is an angiotensin II receptor antagonist that is
metabolised to E-3174. E-3174 is pharmacologically
active and determines largely the antihypertensive e€ects
of losartan [1]. While some studies have shown that the
degradation of losartan to E-3174 is catalysed in vitro by
both CYP2C9 and CYP3A4 [2], others have claimed
that CYP3A4 has a preferential role in this reaction [3].
Fluconazole and itraconazole are widely used anti-
mycotics. Human studies have demonstrated that ¯u-
conazole interacts with drugs metabolised by both
CYP3A4 [4±5] and CYP2C9 [6], whereas itraconazole
interacts more with the substrates of CYP3A4 [7±9]. We,
therefore, wanted to study the e€ects of ¯uconazole and
itraconazole on the pharmacokinetics and pharmaco-
dynamics of losartan and E-3174 in healthy volunteers
to ®nd out the susceptibility of losartan to interaction
with other drugs which have a di€erent spectrum of
inhibition of CYP2C9 and CYP3A4 [10].
Materials, methods and subjects studied
Study design
The study protocol was submitted to the National Agency for
Medicines after being approved by the ethics committee of the
Department of Clinical Pharmacology, University of Helsinki.
Twelve healthy volunteers gave the written informed consent before
entering the study. The 12th volunteer dropped out in the ®rst
phase, the placebo phase for her, before the ingestion of losartan.
The health of the volunteers was ascertained by a medical history, a
clinical examination and laboratory tests including a 12-lead
electrocardiogram (ECG). The subjects (®ve women and six men,
446

aged 18±35 years, weighing 52±82 kg) were non-smokers, and the ables were transformed to natural logarithm when needed for the
only subject receiving continuous medication was one female who statistical test used. The pharmacokinetic and pharmodynamic
was using contraceptive steroids. variables were compared with repeated-measures analysis of vari-
A three-phase, double-blind, randomised, crossover study de- ance (ANOVA) and, as a posteriori test, Tukey's test was used. The
sign was used, with 4-week intervals between phases. The oral statistical signi®cance level was P < 0.05. In addition, the 95%
pretreatment for 4 days was either 200 mg itraconazole daily con®dence interval of the di€erence is shown for selected variables.
(Sporanox, Janssen Pharma, Beerse, Belgium), 400 mg ¯uconazole Systat for Windows, version 6.0.1 (SPSS, Chicago, Ill., USA) was
on day 1 and 200 mg on days 2±4 (Di¯ucan, P®zer, N.Y., USA) or used to analyse the data.
corresponding placebo. On day 4, 1 h after itraconazole, ¯ucona-
zole or placebo, a single 50-mg oral dose of losartan (Cozaar,
MSD, Haarlem, Netherlands) was ingested with 150 ml water.
Before the ingestion of losartan, the subjects fasted for 3 h and a Results
standard meal was served 3 h afterward.
Pharmacokinetic e€ects of ¯uconazole
Blood sampling and determination of drugs
Fluconazole decreased the Cmax and AUC…0±1† of
On day 4, timed blood samples (10 ml each) were drawn into tubes
containing ethylenediaminetetra-acetic acid (EDTA) before the E-3174 to 30% (P < 0.001) and 47% (P < 0.001) of
ingestion of losartan and 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10, 12 and 24 h their control values, respectively, and the t1/2 was in-
afterward. The separation of plasma was carried out within 30 min, creased to 167% (P < 0.01) of control (Fig. 1, Table 1).
after which the samples were stored at )70 °C until analysed. The mean values of AUC(0±24), AUC…0±1† and t1/2 of
Plasma concentrations of losartan and E-3174 were determined by
means of high-performance liquid chromatography (HPLC) [11].
losartan were 23±41% higher during the ¯uconazole
The detection limit was 10 ng á ml)1 for both losartan and E-3174 phase than during the placebo phase, but the di€erences
and the coecient of daily variation 5.6% at 57.8 ng á ml)1 were not statistically signi®cant. Fluconazole decreased
(n ˆ 19) and 3.5% at 55.6 ng á ml)1 (n ˆ 19) for losartan and the Cmax of unchanged losartan to 76% compared with
E-3174, respectively. Itraconazole and hydroxy-itraconazole con- placebo (P < 0.05). The ratio of AUC…0±1†E-3174 to
centrations were analysed by means of HPLC [12±13]. The detec-
tion limit was 10 ng á ml)1 and the day-to-day coecient of
variation was 1.2% at 193.0 ng á ml)1 (n ˆ 8) for itraconazole and
7.2% at 196.0 ng á ml)1 (n ˆ 8) for hydroxy-itraconazole. The
detection limit of the gas chromatographic method [14] used in
¯uconazole analysis was 300 ng á ml)1 with a 3.4% daily coecient
of variation at 522 ng á ml)1.

Pharmacokinetics

The peak concentrations (Cmax) and time to peak concentration

(tmax) were obtained directly from the measured plasma concen-
trations of losartan, E-3174, itraconazole, hydroxy-itraconazole
and ¯uconazole. The linear trapezoidal rule was used for ascending
concentrations and the log-linear trapezoidal rule for descending
concentrations to determine the area under the plasma drug con-
centration±time curve from 0 to 24 h [AUC(0±24)] and it was ex-
trapolated to in®nity to obtain AUC…0±1†. For each subject, the
rate constant (kel) of the terminal elimination phase of losartan and
E-3174 were calculated by regression analysis of the log-linear part
of the concentration±time curve. The half-life (t1/2) of losartan and
E-3174 were calculated from the equation t1/2 ˆ ln2/kel. The
AUC(0±24) of itraconazole, hydroxy-itraconazole and ¯uconazole
refer to the time between 0 and 24 h after the ingestion of losartan,
that is, between 1 and 25 h after the last dose of pretreatment.

Pharmacodynamics

The e€ects of losartan were measured after each blood sampling,

except at 0.5 and 1.5 h. The systolic and diastolic blood pressure as
well as heart rate were measured twice from the forearm, in sitting
position, with a 1-min interval after 15 min rest. The measurements
were carried out by means of an automatic oscillometric blood
pressure monitor (HEM-711, Omron Health Care, Hamburg,
Germany). The mean value of the two measurements was used in
the analysis. The AUC was calculated for the changes in pharma-
codynamic variables using the linear trapezoidal rule for 0±12 h
[AUC(0±12)].
Statistical analysis
Mean values (SD) are presented for all variables, except for the tmax
which is presented as median (range). The pharmacokinetic vari-
Fig. 1 a The mean concentrations of losartan after 50 mg oral
losartan, following 4-day pretreatment with either itraconazole
200 mg daily (s), ¯uconazole (400 mg on day 1 and 200 mg on days
2±4) (j) or placebo (n). b The mean concentrations of E-3174 on the
day of losartan ingestion. Symbols according to di€erent pretreat-
ments: itraconazole (s), ¯uconazole (j) and placebo (n). c The mean
concentrations of itraconazole (d), hydroxy-itraconazole (s) and
¯uconazole (j) on day 4. The time zero is the time of losartan
administration (i.e. 1 h after the ingestion of the last dose of
itraconazole or ¯uconazole). The standard deviation bars have been
omitted for clarity
 447

Table 1 The pharmacokinetic variables [mean (SD); median (200 mg daily), ¯uconazole (400 mg on day 1 and 200 mg on days
(range) for tmax; the 95% con®dence interval for the % of control] 2±4) or placebo. Cmax, peak concentration; tmax, time of peak; t1/2,
of losartan and E-3174 in 11 subjects after a 50-mg oral dose of elimination half-life; AUC…0±t†, area under the concentration-time
losartan, following a 4-day pretreatment with either itraconazole curve from 0 to t hours

Variable Placebo phase Itraconazole phase Fluconazole phase

Control % Control % Control

Losartan
Cmax (ng á ml)1) 223 (143) 204 (131) 98% (70%±127%) 172 (135)a 76% (56%±95%)
tmax (h) 1 (0.5, 3) 1.5 (0.5, 4) 1.5 (0.5, 4)
t1/2 (h) 1.8 (0.6) 1.8 (0.8) 124% (45%±203%) 2.4 (0.7) 141% (116%±166%)
AUC(0±24) (ng á ml)1 á h) 375 (219) 376 (163) 106% (86%±126%) 476 (328) 123% (105%±142%)
AUC…0±1† (ng á ml)1 á h) 375 (219) 376 (163) 106% (86%±126%) 476 (328) 123% (105%±142%)
E-3174
Cmax (ng á ml)1) 239 (108) 223 (115)e 94% (79%±109%) 56 (31)c 30% (14%±47%)
tmax (h) 4 (3, 4) 4 (2, 6) 4 (2, 8)
t1.2(h) 4.5 (1.3) 4.4 (1.8)e 91% (61%±121%) 8.6 (4.3)b 167% (119%±215%)
AUC(0±24) (ng á ml)1 á h) 1550 (660) 1490 (770)d 105% (80%±131%) 660 (370)c 45% (33%±57%)
AUC…0±1† (ng á ml)1 á h) 1780 (460) 1720 (720)e 88% (63%±113%) 940 (570)c 47% (27%±67%)
AUC…0±1†E-3174 5.0 (2.8) 4.6 (2.0)e 91% (61%±120%) 2.5 (3.1)c 39% (19%±58%)
/ AUC…0±1†Losartan
a,b,c
Signi®cantly di€erent from the placebo phase: a (P < 0.05); b (P < 0.01); c (P < 0.001)
d,e
Signi®cantly di€erent from the ¯uconazole phase: d (P < 0.01); e (P < 0.001)

AUC …0±1†losartan was decreased to 40% by ¯uconazole
(P < 0.001 compared with both itraconazole and pla-
cebo) (Table 1).
Pharmacokinetic e€ects of itraconazole
tolic and diastolic blood pressures between phases were
observed, whereas the DAUC(0±12) of heart rate was
lower during both ¯uconazole and itraconazole phases
than during the placebo phase (P < 0.01).

The pharmacokinetics of E-3174 during the itraconazole

phase was similar to that during the placebo phase
(P > 0.05), but all pharmacokinetic parameters of
E-3174, except tmax, were signi®cantly di€erent from
those of the ¯uconazole phase (Fig. 1, Table 1).
Itraconazole had no signi®cant e€ect on the pharma-
cokinetics of losartan compared with placebo or ¯u-
conazole (P > 0.05). In addition, itraconazole had
no e€ect on the ratio of AUC…0±1†E-3174 to AUC-
…0±1†losartan.

Pharmacokinetics of itraconazole, hydroxy-itraconazole

and ¯uconazole

The mean (SD) AUC(0±24) values for itraconazole,

hydroxy-itraconazole and ¯uconazole were 5.9 (4.2) lg á
ml)1 á h, 12.7 (3.3) lg á ml)1 á h and 194 (39) lg á ml)1 á h,
respectively (Fig. 1). The interindividual di€erences in
the pharmacokinetics of itraconazole were large, e.g. the
AUC(0±24) varied by a factor of six, whereas approxi-
mately twofold interindividual di€erences were observed
in the AUC(0±24) of hydroxy-itraconazole and ¯ucon-
azole.

Pharmacodynamics
The blood pressure and heart rate are presented in
Fig. 2. No statistically signi®cant di€erences in the sys-
Fig. 2 The mean (‹SE) systolic (SBP) (a) and diastolic (DBP) (b)
blood pressure, and heart rate (c) after the ingestion of oral losartan
50 mg during itraconazole, ¯uconazole and placebo phases. The
pretreatment was either itraconazole 200 mg daily (d), ¯uconazole
(400 mg on day 1 and 200 mg on days 2±4) (m) or placebo (s) for 4
days
448
Discussion
Fluconazole had only minor e€ects on the pharmaco-
kinetic variables of unchanged losartan, but consider-
ably decreased the Cmax and AUC of the active
metabolite E-3174 and increased its t1/2. Itraconazole, on
the other hand, had no e€ect on the pharmacokinetics of
losartan and E-3174.
The pharmacokinetics of losartan and E-3174 during
the placebo phase of the present study were in accor-
dance with previous data in healthy volunteers, even
including the large intersubject variation [15]. Only
about 14% of losartan is normally metabolised to
E-3174 [15]. Despite its limited formation, the pharma-
cological e€ects of losartan are mediated mainly by this
metabolite, which is eliminated more slowly than
losartan itself [1, 15] and has a greater anity for the
angiotensin II receptors [16].
Fluconazole considerably reduced the formation of
E-3174 from losartan, as can be seen from the greatly
reduced Cmax and AUC values of E-3174. A small,
nonsigni®cant increase in the AUC of unchanged
losartan can be explained by the minor (14%) role of the
E-3174 pathway in the total elimination of losartan [15].
Furthermore, because the distribution volume of E-3174
is only about one third that of losartan, ¯uconazole
caused more pronounced changes in the plasma con-
centrations of E-3174 than losartan. Fluconazole in-
creased the t1/2 of E-3174 about twofold compared with
its control value. Therefore, it is probable that ¯ucona-
zole inhibits not only the metabolism of losartan to
E-3174, but also the further elimination of E-3174.
Losartan is metabolised to E-3174 in vitro by both
CYP3A4 and CYP2C9 [2] and evidence has been pro-
vided for the preferential role of CYP3A4 in this con-
version [3]. In vitro, ¯uconazole, unlike itraconazole, is a
more potent inhibitor of CYP2C9 than of CYP3A4 [10].
In man, ¯uconazole can inhibit both CYP3A4-mediated
[4±5] and CYP2C9-mediated [6] drug metabolism.
However, the CYP3A4-mediated metabolism in man is
a€ected clearly more by itraconazole than by ¯ucona-
zole [4, 5, 8, 9]. In the present study where ¯uconazole
caused a clear pharmacokinetic interaction, itraconazole
did not change the pharmacokinetics of losartan or
E-3174 or the ratio of the AUC values of E-3174 and
losartan. Accordingly, we suggest that, in man, losartan
is metabolised to E-3174 preferably by CYP2C9 and
also that the elimination of E-3174 depends more on
CYP2C9 than CYP3A4.
The pharmacological e€ects of losartan are mediated
mainly by E-3174 and to a minor degree by losartan [1].
In the present study, the systolic and diastolic blood
pressures were similar during all three phases of the
study, though the concentrations of E-3174 were de-
creased by ¯uconazole. It is possible that somewhat in-
creased concentrations of the unchanged losartan,
during the ¯uconazole phase, could compensate the ef-
fect of lowered plasma E-3174 concentrations. The
steady-state concentrations of ¯uconazole were not
reached and only a single dose of losartan was given in
our present study. Prolonged concomitant use of ¯u-
conazole with losartan might lead to a more pronounced
interaction between ¯uconazole and losartan.
In conclusion, ¯uconazole but not itraconazole in-
teracts with losartan by decreasing the metabolism of
losartan to E-3174. We suggest that CYP2C9 is a major
enzyme for the metabolism of losartan to E-3174 in
humans. The clinical signi®cance of the ¯uconazole±
losartan interaction is unclear, but the possibility of a
decreased therapeutic e€ect of losartan should be kept in
mind.
Acknowledgements We would like to acknowledge Merck Sharp &
Dohme for losartan and E-3174. We also want to thank Mr. Jouko
Laitila, Mrs. Lisbet Partanen, Mrs. Eija MaÈkinen-Pulli and Mrs.
Kerttu MaÊrtensson for the skillful determination of drug concen-
trations. This study was supported by a grant from the Helsinki
University Central Hospital Research Fund and by the 350th An-
niversary Fund of the University of Helsinki.
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