Interleukin-6 Inhibitors and Drug-drug Interactions in Patients With Rheumatoid Arthritis

Odense University Hospital, Hospital of South West Jutland, King Christian X´Hospital for Rheumatic Diseases, Sygehus Lillebaelt, Odense Patient Data Explorative Network

With this study the investigators aim to assess if drug metabolism changes in patients with rheumatoid arthritis when an interleukin (IL)-6 inhibitor is initiated. Patients with rheumatoid arthritis have an increased level of inflammation in the body which can lead to decreased expression and activity of drug metabolizing enzymes in the liver. This will lead to a decreased metabolism and excretion of drugs. The inflammation is driven by a number of proinflammatory cytokines e.g., IL-6. The investigators hypothesize that patients with rheumatoid arthritis initiating treatment with an IL-6-receptor inhibitor (anti-IL-6R) will obtain a normalization of the activated IL-6-pathway resulting in increased expression and activity of drug metabolizing enzymes and hence increased metabolism. Ultimately, this normalization of drug metabolism could lead to insufficient efficacy of a wide variety of drugs. The investigators will perform a clinical pharmacokinetic trial. The study will include patients with active rheumatoid arthritis and a need to initiate treatment with an IL-6 receptor antibody. Patients will ingest a 6-drug cocktail consisting of probes for specific CYP enzymes. Plasma and urine will be drawn over 6 hours to determine concentrations of the drugs and their metabolites. Patients will then initiate IL-6 receptor antibody treatment and to assess both short- and long-term impact of altered inflammation, the same 6-drug cocktail will be ingested, and concentrations measured, after three weeks and three months. To help understand the mechanism and the putative involvement of inflammation, markers of inflammation such as cytokines, transcription factors, etc. will also be assesses.

Tocilizumab, 162 mg subcutaneous, once every week OR Sarilumab, 200 mg subcutaneous, once every two weeks.

Tocilizumab and Sarilumab are considered equal. Patients are assigned the treatment based on national and local guidelines. Intervention will be administered according to the approved posology.

Tocilizumab and Sarilumab are considered equal. Patients are assigned the treatment based on national and local guidelines. Intervention will be administered according to the approved posology.

A change in metabolic ratio of midazolam after 3 weeks of treatment with an IL-6Ra as compared to baseline. The metabolic ratio of midazolam is used to assess the activity of CYP3A4.

A change in metabolic ratio of midazolam after 12 weeks of treatment with an IL-6Ra as compared to baseline. The metabolic ratio of midazolam is used to assess the activity of CYP3A4.

A change in metabolic ratio of caffeine after 3 weeks of treatment with an IL-6Ra as compared to baseline. The metabolic ratio of caffeine is used to assess the activity of CYP1A2.

A change in metabolic ratio of caffeine after 12 weeks of treatment with an IL-6Ra as compared to baseline. The metabolic ratio of caffeine is used to assess the activity of CYP1A2.

A change in metabolic ratio of efavirenz after 3 weeks of treatment with an IL-6Ra as compared to baseline. The metabolic ratio of efavirenz is used to assess the activity of CYP2B6.

A change in metabolic ratio of efavirenz after 12 weeks of treatment with an IL-6Ra as compared to baseline. The metabolic ratio of efavirenz is used to assess the activity of CYP2B6.

A change in metabolic ratio of losartan after 3 weeks of treatment with an IL-6Ra as compared to baseline. The metabolic ratio of losartan is used to assess the activity of CYP2C9.

A change in metabolic ratio of losartan after 12 weeks of treatment with an IL-6Ra as compared to baseline. The metabolic ratio of losartan is used to assess the activity of CYP2C9.

A change in metabolic ratio of omeprazole after 3 weeks of treatment with an IL-6Ra as compared to baseline. The metabolic ratio of omeprazole is used to assess the activity of CYP2C9.

A change in metabolic ratio of omeprazole after 12 weeks of treatment with an IL-6Ra as compared to baseline. The metabolic ratio of omeprazole is used to assess the activity of CYP2C9.

A change in metabolic ratio of metoprolol after 3 weeks of treatment with an IL-6Ra as compared to baseline. The metabolic ratio of metoprolol is used to assess the activity of CYP2C9.

A change in metabolic ratio of metoprolol after 12 weeks of treatment with an IL-6Ra as compared to baseline. The metabolic ratio of metoprolol is used to assess the activity of CYP2C9.

A change in inflammation after 3 and 12 weeks of treatment with an IL-6Ra as compared to baseline. measured by a panel of inflammatory markers.

Inclusion Criteria: Active rheumatoid arthritis Age 18-75 years eGFR > 30 mL/min absolute neutrophil count (ANC) ≥ 2 x 109 /L Platelet count > 150 x 103 /μL (corresponding to >150 x 109 /L) ALAT in the normal range or within 1.5x the upper limit of normal. Use of effective contraception (only woman of childbearing potential) Negative test for hepatitis and tuberculosis Exclusion Criteria: Known sensitivity to any of the medications used. Active severe infections Malignancy Diverticulitis Intake of medications which can influence the safety of the patient or the results of the study. Can include prescription medications, over-the-counter medications, herbal medicines or dietary supplements. Will be assessed by the investigators. Participation in other clinical intervention trials. Pregnancy or breastfeeding