Combined isosorbide dinitrate and ibuprofen as a novel therapy for muscular dystrophies: evidence from Phase I studies in healthy volunteers

Abstract

We designed two Phase I studies that assessed healthy volunteers in order to evaluate the safety and to optimize the dosing of the combination of the drugs isosorbide dinitrate, a nitric oxide donor, and ibuprofen, a nonsteroidal antiinflammatory drug. We designed these studies with the aim of designing a Phase II trial to evaluate the drugs' efficacy in patients affected by Duchenne muscular dystrophy. For the first trial, ISOFEN1, a single-dose, randomized-sequence, open-label, active control, three-treatment cross-over study, was aimed at comparing the pharmacokinetics of ibuprofen 200 mg and isosorbide dinitrate 20 mg when given alone and concomitantly. The pharmacokinetics of ibuprofen given alone versus ibuprofen given concomitantly with isosorbide dinitrate were similar, as documented by the lack of statistically significant differences in the main drug's pharmacokinetic parameters (time to maximal concentration [Tmax], maximal concentration [Cmax], area under the curve [AUC]0-t, and AUC0-∞). Similarly, we found that the coadministration of ibuprofen did not significantly affect the pharmacokinetics of isosorbide dinitrate. No issues of safety were detected. The second trial, ISOFEN2, was a single-site, dose titration study that was designed to select the maximum tolerated dose for isosorbide dinitrate when coadministered with ibuprofen. Eighteen out of the 19 enrolled subjects tolerated the treatment well, and they completed the study at the highest dose of isosorbide dinitrate applied (80 mg/day). One subject voluntarily decided to reduce the dose of isosorbide dinitrate from 80 mg to 60 mg. The treatment-related adverse events recorded during the study were, for the large majority, episodes of headache that remitted spontaneously in 0.5-1 hour - a known side effect of isosorbide dinitrate. These studies demonstrate that the combination of isosorbide dinitrate and ibuprofen does not lead to pharmacokinetic interactions between the two drugs; they also demonstrate that the combination of isosorbide dinitrate and ibuprofen has optimal tolerability and safety profiles that are similar to those previously reported for isosorbide dinitrate and ibuprofen given alone.

Keywords: adverse events; coadministration; ibuprofen; isosorbide dinitrate; pharmacokinetic profile.

Figure 1

Flow chart of the ISOFEN2 study. Abbreviations: IBU, ibuprofen; ISO, isosorbide dinitrate; DBP, diastolic blood pressure.

Figure 2

Pharmacokinetic profiles of isosorbide and ibuprofen after the administration of ISO, ibuprofen, or their combination. Notes: (A) Ibuprofen profile; (B) isosorbide profile representing the mean (standard deviation) plasma drug concentrations over time, as measured in healthy volunteers (n=12) given each drug alone (black circles) or in combination (white circles). Abbreviations: ISO, isosorbide dinitrate; n, number.

Figure 3

Time course of diastolic blood pressure variations during the study. Notes: Diastolic blood pressure was measured at the different study visits in which ISO doses were up-titrated from 20 mg to 80 mg once daily at predose and 1 hour and 3 hours postdose. Abbreviation: ISO, isosorbide dinitrate.

Figure 4

Time course of systolic blood pressure variations during the study. Notes: Systolic blood pressure was measured at the different study visits in which isosorbide doses were up-titrated from 20 mg to 80 mg once daily at predose and 1 hour and 3 hours postdose. Abbreviation: ISO, isosorbide dinitrate.