Drug Interaction Report

MONITOR: Coadministration of bosentan with a drug that is both a substrate as well as inhibitor of CYP450 2C9 and/or 3A4 may result in increased plasma concentrations of bosentan and decreased plasma concentrations of the other drug. Bosentan itself is a substrate and inducer of both CYP450 2C9 and 3A4. Theoretically, bosentan may induce metabolism of the coadministered drug while its own metabolism may be inhibited by the coadministered drug. According to the product labeling, administration of bosentan (125 mg orally twice a day) in combination with the potent CYP450 3A4 inhibitor ketoconazole resulted in approximately 2-fold increases in bosentan plasma concentrations. It is conceivable that concomitant administration of both a CYP450 2C9 inhibitor and a CYP450 3A4 inhibitor may lead to even larger increases in bosentan plasma concentrations.

MANAGEMENT: When a drug that is both a substrate as well as inhibitor of CYP450 2C9 and/or 3A4 is coadministered with bosentan, the possibility of diminished therapeutic response to the coadministered drug should be considered. Clinical and/or laboratory monitoring may be appropriate whenever bosentan is added to or withdrawn from therapy, and the dosage of the concomitant drug adjusted as necessary. The possibility of prolonged and/or increased pharmacologic effects of bosentan, including serious adverse effects such as hepatotoxicity, should also be considered. Patients should be advised to notify their physician if they experience signs and symptoms of hepatotoxicity such as fever, rash, anorexia, nausea, vomiting, fatigue, right upper quadrant pain, dark urine, and jaundice. Concomitant administration of bosentan with both a potent CYP450 2C9 inhibitor (e.g., fluconazole, amiodarone) and a potent CYP450 3A4 inhibitor (e.g., ketoconazole, itraconazole, ritonavir) is not recommended. Concomitant administration with combination CYP450 2C9/3A4 inhibitors (e.g., delavirdine, imatinib, miconazole, mifepristone, voriconazole) should probably be avoided also, if possible.

GENERALLY AVOID: Alcohol may potentiate some of the pharmacologic effects of CNS-active agents. Use in combination may result in additive central nervous system depression and/or impairment of judgment, thinking, and psychomotor skills.

MANAGEMENT: Patients receiving CNS-active agents should be warned of this interaction and advised to avoid or limit consumption of alcohol. Ambulatory patients should be counseled to avoid hazardous activities requiring complete mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.