Atorvastatin Coadministration May Increase Digoxin Concentrations by Inhibition of Intestinal P‐Glycoprotein‐Mediated Secretion

The effect of atorvastatin on digoxin pharmacokinetics was assessed in 24 healthy volunteers in two studies. Subjects received 0.25 mg digoxin daily for 20 days, administered alone for the first 10 days and concomitantly with 10 mg or 80 mg atorvastatin for the last 10 days. Mean steady‐state plasma digoxin concentrations were unchanged by administration of 10 mg atorvastatin. Mean steady‐state plasma digoxin concentrations following administration of digoxin with 80 mg atorvastatin were slightly higher than concentrations following administration of digoxin alone, resulting in 20% and 15% higher Cmax and AUC(0.24) values, respectively Since tmax and renal clearance were not significantly affected, the results are consistent with an increase in the extent of digoxin absorption in the presence of atorvastatin. Digoxin is known to undergo intestinal secretion mediated by P‐glycoprotein. Since atorvastatin is a CYP3A4 substrate and many CYP3A4 substrates are also substrates for P‐glycoprotein transport, the influence of atorvastatin and its metabolites on P‐glycoprotein‐mediated digoxin transport in monolayers of the human colon carcinoma (Caco‐2) cell line was investigated. In this model system, atorvastatin exhibited efflux or secretion kinetics with a Km of 110 μM. Atorvastatin (100 μM) inhibited digoxin secretion (transport from the basolateral to apical aspect of the monolayer) by 58%, equivalent to the extent of inhibition observed with verapamil, a known inhibitor of P‐glycoprotein transport. Thus, the increase in steady‐state digoxin concentrations produced by 80 mg atorvastatin coadministration may result from inhibition of digoxin secretion into the intestinal lumen.