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national institute of allergy and infectious diseases
DESCRIPTION
Zafirlukast is a synthetic, selective peptide leukotriene receptor antagonist(LTRA), with the chemical name 4-(5-cyclopentyloxy-carbonylamino-1-methyl-indol-3-ylmethyl)-3-methoxy-N-o-tolylsulfonylbenzamide national institute of allergy and infectious diseases. The molecular weight of zafirlukast is 575.7 and the structural formula is:

The empirical formula is: C 31 H 33 N 3 O 6 S

Zafirlukast, a fine white to pale yellow amorphous powder, is practically insolublein water national institute of allergy and infectious diseases. It is slightly soluble in methanol and freely soluble in tetrahydrofuran,dimethylsulfoxide, and acetone national institute of allergy and infectious diseases.

ACCOLATE is supplied as 10 and 20 mg tablets for oral administration national institute of allergy and infectious diseases.

Inactive Ingredients: Film-coated tablets containing croscarmellose sodium,lactose, magnesium stearate, microcrystalline cellulose, povidone, hypromellose,and titanium dioxide national institute of allergy and infectious diseases.

CLINICAL PHARMACOLOGY
Mechanism of Action
Zafirlukast is a selective and competitive receptor antagonist of leukotrieneD 4 and E 4 (LTD 4 and LTE 4 ), components of slow-reacting substance of anaphylaxis(SRSA) national institute of allergy and infectious diseases. Cysteinyl leukotriene production and receptor occupation have been correlatedwith the pathophysiology of asthma, including airway edema, smooth muscle constriction,and altered cellular activity associated with the inflammatory process, whichcontribute to the signs and symptoms of asthma national institute of allergy and infectious diseases. Patients with asthma were foundin one study to be 25-100 times more sensitive to the bronchoconstricting activityof inhaled LTD 4 than nonasthmatic subjects national institute of allergy and infectious diseases.

In vitro studies demonstrated that zafirlukast antagonized the contractileactivity of three leukotrienes (LTC 4 , LTD 4 and LTE 4 ) in conducting airwaysmooth muscle from laboratory animals and humans national institute of allergy and infectious diseases. Zafirlukast prevented intradermalLTD 4 -induced increases in cutaneous vascular permeability and inhibited inhaledLTD 4 -induced influx of eosinophils into animal lungs national institute of allergy and infectious diseases. Inhalational challengestudies in sensitized sheep showed that zafirlukast suppressed the airway responsesto antigen; this included both the early- and late-phase response and the nonspecifichyperresponsiveness national institute of allergy and infectious diseases.

In humans, zafirlukast inhibited bronchoconstriction caused by several kindsof inhalational challenges national institute of allergy and infectious diseases. Pretreatment with single oral doses of zafirlukastinhibited the bronchoconstriction caused by sulfur dioxide and cold air in patientswith asthma national institute of allergy and infectious diseases. Pretreatment with single doses of zafirlukast attenuated the early-and late-phase reaction caused by inhalation of various antigens such as grass,cat dander, ragweed, and mixed antigens in patients with asthma national institute of allergy and infectious diseases. Zafirlukastalso attenuated the increase in bronchial hyperresponsiveness to inhaled histaminethat followed inhaled allergen challenge national institute of allergy and infectious diseases.

Clinical Pharmacokinetics and Bioavailability:
Absorption
Zafirlukast is rapidly absorbed following oral administration national institute of allergy and infectious diseases. Peak plasma concentrationsare generally achieved 3 hours after oral administration national institute of allergy and infectious diseases. The absolute bioavailabilityof zafirlukast is unknown national institute of allergy and infectious diseases. In two separate studies, one using a high fat andthe other a high protein meal, administration of zafirlukast with food reducedthe mean bioavailability by approximately 40% national institute of allergy and infectious diseases.

Distribution
Zafirlukast is more than 99% bound to plasma proteins, predominantly albumin national institute of allergy and infectious diseases. The degree of binding was independent of concentration in the clinically relevantrange national institute of allergy and infectious diseases. The apparent steady-state volume of distribution (V SS /F) is approximately70 L, suggesting moderate distribution into tissues national institute of allergy and infectious diseases. Studies in rats using radiolabeledzafirlukast indicate minimal distribution across the blood-brain barrier national institute of allergy and infectious diseases.

Metabolism
Zafirlukast is extensively metabolized national institute of allergy and infectious diseases. The most common metabolic products arehydroxylated metabolites which are excreted in the feces national institute of allergy and infectious diseases. The metabolites ofzafirlukast identified in plasma are at least 90 times less potent as LTD 4receptor antagonists than zafirlukast in a standard in vitro test of activity national institute of allergy and infectious diseases. In vitro studies using human liver microsomes showed that the hydroxylated metabolitesof zafirlukast excreted in the feces are formed through the cytochrome P4502C9 (CYP2C9) pathway national institute of allergy and infectious diseases. Additional in vitro studies utilizing human liver microsomesshow that zafirlukast inhibits the cytochrome P450 CYP3A4 and CYP2C9 isoenzymesat concentrations close to the clinically achieved total plasma concentrations(see Drug Interactions ) national institute of allergy and infectious diseases.

Excretion
The apparent oral clearance (CL/f) of zafirlukast is approximately 20 L/h national institute of allergy and infectious diseases. Studiesin the rat and dog suggest that biliary excretion is the primary route of excretion national institute of allergy and infectious diseases. Following oral administration of radiolabeled zafirlukast to volunteers, urinaryexcretion accounts for approximately 10% of the dose and the remainder is excretedin feces national institute of allergy and infectious diseases. Zafirlukast is not detected in urine national institute of allergy and infectious diseases.

In the pivotal bioequivalence study, the mean terminal half-life of zafirlukastis approximately 10 hours in both normal adult subjects and patients with asthma national institute of allergy and infectious diseases. In other studies, the mean plasma half-life of zafirlukast ranged from approximately8 to 16 hours in both normal subjects and patients with asthma national institute of allergy and infectious diseases. The pharmacokineticsof zafirlukast are approximately linear over the range from 5 mg to 80 mg national institute of allergy and infectious diseases. Steady-stateplasma concentrations of zafirlukast are proportional to the dose and predictablefrom single-dose pharmacokinetic data national institute of allergy and infectious diseases. Accumulation of zafirlukast in the plasmafollowing twice-daily dosing is approximately 45% national institute of allergy and infectious diseases.

The pharmacokinetic parameters of zafirlukast 20 mg administered as a singledose to 36 male volunteers are shown with the table below national institute of allergy and infectious diseases.

Mean (% Coefficient of Variation) pharmacokinetic
parameters of zafirlukast following single 20 mg
oral dose administration to male volunteers (n=36) C max
ng/mL t max h AUC
ng·h/mL t 1/2
h CL/f
L/h
326 (31.0) 2 (0.5-5.0) 1137 (34) 13.3 (75.6) 19.4 (32)
1 Median and range

Special Populations
Gender: The pharmacokinetics of zafirlukast are similar in males and females national institute of allergy and infectious diseases. Weight-adjusted apparent oral clearance does not differ due to gender national institute of allergy and infectious diseases.

Race: No differences in the pharmacokinetics of zafirlukast due to race havebeen observed national institute of allergy and infectious diseases.

Elderly: The apparent oral clearance of zafirlukast decreases with age national institute of allergy and infectious diseases. Inpatients above 65 years of age, there is an approximately 2-3 fold greater Cmax and AUC compared to young adult patients national institute of allergy and infectious diseases.

Children: Following administration of a single 20 mg dose of zafirlukast to20 boys and girls between 7 and 11 years of age, and in a second study, to 29boys and girls between 5 and 6 years of age, the following pharmacokinetic parameterswere obtained:

Parameter Children age
5-6 years
Mean (% Coefficient
of Variation) Children age
7-11 years
Mean (% Coefficient
of Variation)
C max (ng/mL) 756 (39%) 601 (45%)
AUC (ng·h/mL) 2458 (34%) 2027 (38%)
t max (h) 2.1 (61%) 2.5 (55%)
CL/f (L/h) 9.2 (37%) 11.4 (42%)

Weight unadjusted apparent clearance was 11.4 L/h (42%) in the 7-11 year oldchildren and 9.2 L/h (37%) in the 5-6 year old children, which resulted in greatersystemic drug exposures than that obtained in adults for an identical dose national institute of allergy and infectious diseases. To maintain similar exposure levels in children compared to adults, a dose of10 mg twice daily is recommended in children 5-11 years of age (see DOSAGE ANDADMINISTRATION ) national institute of allergy and infectious diseases.

Zafirlukast disposition was unchanged after multiple dosing (20 mg twice daily)in children and the degree of accumulation in plasma was similar to that observedin adults national institute of allergy and infectious diseases.

Hepatic Insufficiency: In a study of patients with hepatic impairment (biopsy-provencirrhosis), there was a reduced clearance of zafirlukast resulting in a 50-60%greater C max and AUC compared to normal subjects national institute of allergy and infectious diseases.

Renal Insufficiency: Based on a cross-study comparison, there are no apparentdifferences in the pharmacokinetics of zafirlukast between renally-impairedpatients and normal subjects national institute of allergy and infectious diseases.

Drug-Drug Interactions
The following drug interaction studies have been conducted with zafirlukast(see PRECAUTIONS , Drug Interactions ) national institute of allergy and infectious diseases.

Coadministration of multiple doses of zafirlukast (160 mg/day) to steady-statewith a single 25 mg dose of warfarin (a substrate of CYP2C9) resulted in a significantincrease in the mean AUC (+63%) and half-life (+36%) of S-warfarin national institute of allergy and infectious diseases. The meanprothrombin time increased by approximately 35% national institute of allergy and infectious diseases. The pharmacokinetics of zafirlukastwere unaffected by coadministration with warfarin national institute of allergy and infectious diseases.
Coadministration of zafirlukast (80 mg/day) at steady-state with a single doseof a liquid theophylline preparation (6 mg/kg) in 13 asthmatic patients, 18to 44 years of age, resulted in decreased mean plasma concentrations of zafirlukastby approximately 30%, but no effect on plasma theophylline concentrations wasobserved national institute of allergy and infectious diseases.
Coadministration of zafirlukast (20 mg/day) or placebo at steady-state witha single dose of sustained release theophylline preparation (16 mg/kg) in 16healthy boys and girls (6 through 11 years of age) resulted in no significantdifferences in the pharmacokinetic parameters of theophylline national institute of allergy and infectious diseases.
Coadministration of zafirlukast dosed at 40 mg twice daily in a single-blind,parallel-group, 3-week study in 39 healthy female subjects taking oral contraceptives,resulted in no significant effect on ethinyl estradiol plasma concentrationsor contraceptive efficacy national institute of allergy and infectious diseases.
Coadministration of zafirlukast (40 mg/day) with aspirin (650 mg four timesdaily) resulted in mean increased plasma concentrations of zafirlukast by approximately45% national institute of allergy and infectious diseases.
Coadministration of a single dose of zafirlukast (40 mg) with erythromycin (500mg three times daily for 5 days) to steady-state in 11 asthmatic patients resultedin decreased mean plasma concentrations of zafirlukast by approximately 40%due to a decrease in zafirlukast bioavailability national institute of allergy and infectious diseases.

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