• Mikko T Holmberg, Aleksi Tornio, Lotta Joutsi-Korhonen, Mikko Neuvonen, Pertti J Neuvonen, Riitta Lassila, Mikko Niemi, and Janne T Backman.
• Department of Clinical Pharmacology, University of Helsinki and HUSLAB, Helsinki, Finland.
• Br J Clin Pharmacol. 2013 Jun 1; 75 (6): 1488-96.

AimThis study examined the effects of grapefruit juice on the new P2Y12 inhibitor ticagrelor, which is a substrate of CYP3A4 and P-glycoprotein.MethodsIn a randomized crossover study, 10 healthy volunteers ingested 200 ml of grapefruit juice or water thrice daily for 4 days. On day 3, they ingested a single 90 mg dose of ticagrelor.ResultsGrapefruit juice increased ticagrelor geometric mean peak plasma concentration (Cmax ) to 165% (95% confidence interval 147, 184%) and area under the concentration-time curve (AUC(0,∞)) to 221% of control (95% confidence interval 200, 245%). The Cmax and AUC(0,34 h) (P < 0.05) but not the AUC(0,∞) of the active metabolite C12490XX were decreased significantly. Grapefruit juice had a minor effect on ticagrelor elimination half-life prolonging it from 6.7 to 7.2 h (P = 0.036). In good correlation with the elevated plasma ticagrelor concentrations, grapefruit juice enhanced the antiplatelet effect of ticagrelor, assessed with VerifyNow® and Multiplate® methods, and postponed the recovery of platelet reactivity.ConclusionsGrapefruit juice increased ticagrelor exposure by more than two-fold, leading to an enhanced and prolonged ticagrelor antiplatelet effect. The grapefruit juice-ticagrelor interaction seems clinically important and indicates the significance of intestinal metabolism to ticagrelor pharmacokinetics.© 2012 The Authors. British Journal of Clinical Pharmacology © 2012 The British Pharmacological Society.

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