Eur J ClinPharmacol(1990) 38:555-560
©
Springer-Verlag1990
The effect of ketoconazole and transdermal estradiol on serum sex steroid hormones levels G. S. Hughes, S. E Francom, C. R. Spillers, and T. V. Ringer ClinicalPharmacologyand Biostatistics,UpjohnResearch Clinics,The Upjohn Company,Kalamazoo,MichiganU. S.A. Received: August 29,1989/Acceptedin revisedform:January24,1990
Summary.In this randomized, open-label trial, 24 subjects were studied. There were 12 subjects with essential hypertension and 12 normotensive controls who received, after an initial control period, 48 h of treatment with a transdermal estradiol patch or ketoconazole tablets every 8 h for six doses, or in combination. L H R H (100 ~tg) and ACTH (250 gg) were given at 48 h of each treatment. Each treatment was one week apart. In both normotensive and hypertensive men ketoconazole reduced adrenal and gonadal androgens, raised 11-deoxycortisol and 17 a-hydroxyprogesterone levels; blunted the rise of cortisol to ACTH and had no effect on the response of LH to LHRH. Transdermal estradiol raised serum estradiol levels, blunted the time to peak plasma concentration of LH to L H R H and produced a normal response to ACTH. Although baseline level of total and free testosterone and DHEA-S were lower in hypertensive men, the response of the pituitary (LH) to LHRH and adrenal axis with ACTH were similar in both normotensive and hypertensive men. Blood pressure was unaffacted by any of the treatment interventions in either normotensive or hypertensive men. Although ketoconazole or transdermal estradiol reduce androgens, there was no evidence that this reduction in androgens was involved with the short term regulation of blood pressure in hypertensive men. Key words: ketoconazole, testosterone, estradiol; estradiol patch, LHRH, ACTH, healthy volunteers, essential hypertension
Endogenous sex steroid hormones have been implicated to the pathophysiology of cardiovascular diseases or disease processes such as atherosclerosis [1-3], coronary artery disease (angina and myocardial infarction) [4-8], and essential hypertension [2, 3, %12], but their role in these disorders is highly controversial. A drug (or drugs) which could temporarily and reversibly perturb endogenous sex
steroid hormones could help to examine relationships among known cardiac risk factors such as blood pressure and changes in circulating hormone levels. Two commonly prescribed agents, ketoconazole, an imidazole antifungal drug for oral use [13], and a transdermal estradiol patch, used for menopausal symptoms [14], can produce reduction of levels of androgens and elevation of estrogens similar to those seen in men with hypertension [9,12, 15]. Ketoconazole acts by blockade of multiple steps in gonadal and adrenal androgen synthesis with secondary elevation of estrogens and luteinizing hormone (LH) [13]. Estradiol decreased L H R H and/or LH with reduction of testosterone [14]. Transdermal estradiol, unlike oral estrogen, can produce reduction of androgens but without confounding elevation in sex hormone binding globulin or elevation in plasma renin activity [14]. Both of these drugs produce maximal and fully reversible effects by 2448 h. Thus, these drugs could serve as pharmacologic probes to study the acute effects of circulating levels of sex steroid hormones on the hypothalamic-pituitary-adrenal axis and blood pressure in normotensive men and men with essential hypertension without changing the renin-angiotensin system or hormone interactions with sex hormone binding globulin [14]. The purpose of this study was to determine whether the acute administration of ketoconazole and/or transdermal estradiol could alter circulating levels of sex steroid hormones, the response of the hypothalamic-pituitary-adrenal axis to L H R H and ACTH, and blood pressure in normotensive men and men with essential hypertension.
Methods
Subjects and protocol Twenty-fourmales,who were nonsmokersand free of substanceand alcohol abuse, between the ages of 19 and 41 volunteered for the study.Twelvesubjects were normotensive(26.2 (7.1) y) and 12 subjects (ages 27.9 (1.5) y) had essential hypertension. Patients with
G. S. Hughes et at.: Sex steroid hormone levels and ketoconazole
556 Table 1. Sampling schedule for selected laboratory tests determining the effects of ketoconazole and transdermal estradiol on plasma sex steroid hormones and the response of the hypothalamic-pituitary-adrenal axis to LHRH and A C T H
Minutes ~ -15
-5
15
30
45
60
120
LH
X°
X~
X
X
X
X
X
Prolactin
X~
Xa X
X
X
X
X
X
X
Cortisol
X
ll-deoxycortisol
X
X
17-hydroxyprogesterone
X
X
X
X
DHEA-S
X
X
X
X
Androstenedione
X
X
X
X
Testosterone (free and total)
X
X
X
X
Estradiol
X
X
X
X
X
X
X
X Estrone Time is measured with respect to administration of LHRt-I and ACTH
essential hypertension had a diastolic blood pressure (in supine position) of at least 90 mm Hg using a blood pressure monitor (Dinamap TM,Critikon, Inc., Tampa, FL) on three separate occasions. Each subject was free of medications, including antihypertensive drugs, for at least 2 weeks before the study. There was no evidence of secondary hypertension by history, physical examination, or laboratory studies. All subjects (normotensive and hypertensives) consumed an isocaloric diet with the following daily intake: sodium, 150 retool; potassium, 60 mmol; calcium, 800 big;and phosphorus, 1200 mg during the study. All subjects gave informed consent and had normal findings on medical history and physical examination and routine laboratory studies, a 12-lead electrocardiogram done at rest, and body fat determination by bioelectrical impedance analysis [16]. The proto-
col was approved by the Upjohn Protocol Review Committee and the Human Use Committee of Bronson Methodist Hospital (Kalamazoo, MI). Subjects meeting all of the entrance criteria were entered into the study. Treatment periods were 48 h tong and were separated from each other by I week in order to allow for recovery of the hypothalamicpituitary axis [17]. There was an initial 48 h control period followed by randomization to three treatment periods. During these treatment periods subjects received either ketoconazole alone (Nizoral ®, Janssen, 200 mg tablets; 300 mg, one and one half tablets every 8 h for six doses), transdermal estradiol patch alone (Estraderm ®, Ciba, 0.05 mg patch placed on the left lateral thorax), or both drugs combined. Subjects were admitted to the Upjohn Research Clinics 36 h after the initiation of the control and each treatment period. LHRH (Factrel ®, Ayerst) 100 gg powder in one ml of normal saline and ACTH (Cortrosyn ®, Organon) 250 btg were given in rapid succession by vein [17] in the morning following a 12-h fast (48 h after the first treatments were started). Baseline and serial hormone measurements were obtained as listed in Table 1. Radioimmunoassays were performed at SmithKline Bio-Science Laboratories (Van Nuys, CA) [18]. Subjects returned each week for the following: urine drug screen, measurement of vital signs with a blood pressure monitor, assessment of compliance with medications by pill counts and for proper placement of the patch and safety laboratory studies (complete blood count, liver enzymes, serum lipids and creatinine and a 24-h urine collection). Body fat measurements were performed at the beginning of each study period by bioelectrical impedance analysis, as above [16]. All patients with essential hypertension were classified as having normal renin hypertension by method of Brunnet et aL [19].
Statistical and pharmacokinetic analysis Maximum concentration (Cm=) and the time to peak plasma concentration (t,,ax), for LH were estimated by inspection. The area under the plasma concentration time curve (AUC) was estimated using the trapezoid rule. The estimated pharmacokinetic parameters and baseline data (defined as the time point immediately prior to the administration of LHRH and ACTH) were analyzed using analysis of
Table 2. The effects of ketoconazole and transdermal estradiol on selected gonadal and adrenal hormones (n = 12) in normotensive and hyertensive men (n = 12) (mean and (SD)) Control Estradiol Ketoconazole Ketoconazole/Estradiol P-value* Testosterone, total (nmol-1-1) [14-38]
N H P'~
19.6 (4.5) 11.8 (3.9) 0.0002
17.2 (4.5) 10.5 (3.6) 0.006
4.7 (2.0) 2.1 (0.7) 0.10
3.1 (1.4) 1.2 (0.7) 0.03
0.0001 a, b, c, d 0.0003 a,u.c.d
Testosterone, free (nmol- 1- t) [
©
Springer-Verlag1990
The effect of ketoconazole and transdermal estradiol on serum sex steroid hormones levels G. S. Hughes, S. E Francom, C. R. Spillers, and T. V. Ringer ClinicalPharmacologyand Biostatistics,UpjohnResearch Clinics,The Upjohn Company,Kalamazoo,MichiganU. S.A. Received: August 29,1989/Acceptedin revisedform:January24,1990
Summary.In this randomized, open-label trial, 24 subjects were studied. There were 12 subjects with essential hypertension and 12 normotensive controls who received, after an initial control period, 48 h of treatment with a transdermal estradiol patch or ketoconazole tablets every 8 h for six doses, or in combination. L H R H (100 ~tg) and ACTH (250 gg) were given at 48 h of each treatment. Each treatment was one week apart. In both normotensive and hypertensive men ketoconazole reduced adrenal and gonadal androgens, raised 11-deoxycortisol and 17 a-hydroxyprogesterone levels; blunted the rise of cortisol to ACTH and had no effect on the response of LH to LHRH. Transdermal estradiol raised serum estradiol levels, blunted the time to peak plasma concentration of LH to L H R H and produced a normal response to ACTH. Although baseline level of total and free testosterone and DHEA-S were lower in hypertensive men, the response of the pituitary (LH) to LHRH and adrenal axis with ACTH were similar in both normotensive and hypertensive men. Blood pressure was unaffacted by any of the treatment interventions in either normotensive or hypertensive men. Although ketoconazole or transdermal estradiol reduce androgens, there was no evidence that this reduction in androgens was involved with the short term regulation of blood pressure in hypertensive men. Key words: ketoconazole, testosterone, estradiol; estradiol patch, LHRH, ACTH, healthy volunteers, essential hypertension
Endogenous sex steroid hormones have been implicated to the pathophysiology of cardiovascular diseases or disease processes such as atherosclerosis [1-3], coronary artery disease (angina and myocardial infarction) [4-8], and essential hypertension [2, 3, %12], but their role in these disorders is highly controversial. A drug (or drugs) which could temporarily and reversibly perturb endogenous sex
steroid hormones could help to examine relationships among known cardiac risk factors such as blood pressure and changes in circulating hormone levels. Two commonly prescribed agents, ketoconazole, an imidazole antifungal drug for oral use [13], and a transdermal estradiol patch, used for menopausal symptoms [14], can produce reduction of levels of androgens and elevation of estrogens similar to those seen in men with hypertension [9,12, 15]. Ketoconazole acts by blockade of multiple steps in gonadal and adrenal androgen synthesis with secondary elevation of estrogens and luteinizing hormone (LH) [13]. Estradiol decreased L H R H and/or LH with reduction of testosterone [14]. Transdermal estradiol, unlike oral estrogen, can produce reduction of androgens but without confounding elevation in sex hormone binding globulin or elevation in plasma renin activity [14]. Both of these drugs produce maximal and fully reversible effects by 2448 h. Thus, these drugs could serve as pharmacologic probes to study the acute effects of circulating levels of sex steroid hormones on the hypothalamic-pituitary-adrenal axis and blood pressure in normotensive men and men with essential hypertension without changing the renin-angiotensin system or hormone interactions with sex hormone binding globulin [14]. The purpose of this study was to determine whether the acute administration of ketoconazole and/or transdermal estradiol could alter circulating levels of sex steroid hormones, the response of the hypothalamic-pituitary-adrenal axis to L H R H and ACTH, and blood pressure in normotensive men and men with essential hypertension.
Methods
Subjects and protocol Twenty-fourmales,who were nonsmokersand free of substanceand alcohol abuse, between the ages of 19 and 41 volunteered for the study.Twelvesubjects were normotensive(26.2 (7.1) y) and 12 subjects (ages 27.9 (1.5) y) had essential hypertension. Patients with
G. S. Hughes et at.: Sex steroid hormone levels and ketoconazole
556 Table 1. Sampling schedule for selected laboratory tests determining the effects of ketoconazole and transdermal estradiol on plasma sex steroid hormones and the response of the hypothalamic-pituitary-adrenal axis to LHRH and A C T H
Minutes ~ -15
-5
15
30
45
60
120
LH
X°
X~
X
X
X
X
X
Prolactin
X~
Xa X
X
X
X
X
X
X
Cortisol
X
ll-deoxycortisol
X
X
17-hydroxyprogesterone
X
X
X
X
DHEA-S
X
X
X
X
Androstenedione
X
X
X
X
Testosterone (free and total)
X
X
X
X
Estradiol
X
X
X
X
X
X
X
X Estrone Time is measured with respect to administration of LHRt-I and ACTH
essential hypertension had a diastolic blood pressure (in supine position) of at least 90 mm Hg using a blood pressure monitor (Dinamap TM,Critikon, Inc., Tampa, FL) on three separate occasions. Each subject was free of medications, including antihypertensive drugs, for at least 2 weeks before the study. There was no evidence of secondary hypertension by history, physical examination, or laboratory studies. All subjects (normotensive and hypertensives) consumed an isocaloric diet with the following daily intake: sodium, 150 retool; potassium, 60 mmol; calcium, 800 big;and phosphorus, 1200 mg during the study. All subjects gave informed consent and had normal findings on medical history and physical examination and routine laboratory studies, a 12-lead electrocardiogram done at rest, and body fat determination by bioelectrical impedance analysis [16]. The proto-
col was approved by the Upjohn Protocol Review Committee and the Human Use Committee of Bronson Methodist Hospital (Kalamazoo, MI). Subjects meeting all of the entrance criteria were entered into the study. Treatment periods were 48 h tong and were separated from each other by I week in order to allow for recovery of the hypothalamicpituitary axis [17]. There was an initial 48 h control period followed by randomization to three treatment periods. During these treatment periods subjects received either ketoconazole alone (Nizoral ®, Janssen, 200 mg tablets; 300 mg, one and one half tablets every 8 h for six doses), transdermal estradiol patch alone (Estraderm ®, Ciba, 0.05 mg patch placed on the left lateral thorax), or both drugs combined. Subjects were admitted to the Upjohn Research Clinics 36 h after the initiation of the control and each treatment period. LHRH (Factrel ®, Ayerst) 100 gg powder in one ml of normal saline and ACTH (Cortrosyn ®, Organon) 250 btg were given in rapid succession by vein [17] in the morning following a 12-h fast (48 h after the first treatments were started). Baseline and serial hormone measurements were obtained as listed in Table 1. Radioimmunoassays were performed at SmithKline Bio-Science Laboratories (Van Nuys, CA) [18]. Subjects returned each week for the following: urine drug screen, measurement of vital signs with a blood pressure monitor, assessment of compliance with medications by pill counts and for proper placement of the patch and safety laboratory studies (complete blood count, liver enzymes, serum lipids and creatinine and a 24-h urine collection). Body fat measurements were performed at the beginning of each study period by bioelectrical impedance analysis, as above [16]. All patients with essential hypertension were classified as having normal renin hypertension by method of Brunnet et aL [19].
Statistical and pharmacokinetic analysis Maximum concentration (Cm=) and the time to peak plasma concentration (t,,ax), for LH were estimated by inspection. The area under the plasma concentration time curve (AUC) was estimated using the trapezoid rule. The estimated pharmacokinetic parameters and baseline data (defined as the time point immediately prior to the administration of LHRH and ACTH) were analyzed using analysis of
Table 2. The effects of ketoconazole and transdermal estradiol on selected gonadal and adrenal hormones (n = 12) in normotensive and hyertensive men (n = 12) (mean and (SD)) Control Estradiol Ketoconazole Ketoconazole/Estradiol P-value* Testosterone, total (nmol-1-1) [14-38]
N H P'~
19.6 (4.5) 11.8 (3.9) 0.0002
17.2 (4.5) 10.5 (3.6) 0.006
4.7 (2.0) 2.1 (0.7) 0.10
3.1 (1.4) 1.2 (0.7) 0.03
0.0001 a, b, c, d 0.0003 a,u.c.d
Testosterone, free (nmol- 1- t) [
