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\begin{document}

\title{Effects of Rifampicin on the Pharmacokinetics and Safety of Carotegrast
Methyl in Healthy Subjects: A Randomized 2 x 2 Crossover Study}



\author[1]{Hiromitsu Imai}%
\author[2]{Ichiro Oikawa}%
\author[3]{Tetsuya Koyama}%
\author[4]{Shunji  Matsuki}%
\affil[1]{Oita University Faculty of Medicine}%
\affil[2]{Oita University Faculty Of Medicine Graduate School of Medicine}%
\affil[3]{EA Pharma Co Ltd}%
\affil[4]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 24, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Aims: To evaluate the effect of the combination of carotegrast methyl
with rifampicin, a potent inhibitor of organic anion transporter
polypeptide, on the pharmacokinetics (PK), safety and tolerability.
Methods: In this 2 x 2 crossover study in 20 healthy Japanese adults, 10
subjects received carotegrast methyl 960 mg and rifampicin 600 mg on day
1, and received carotegrast methyl 960 mg on day 8. The subjects in the
other sequence received the same treatments but in the opposite order.
When the 90\% confidence interval (CI) of the geometric mean ratio of
the AUC\textsubscript{0-t} and C\textsubscript{max} for carotegrast, the
main active metabolite of carotegrast methyl, with/without rifampicin
fell within the range of 0.80 -- 1.25, it was deemed that no PK
interaction occurred. Adverse events (AEs) were monitored. Results: The
C\textsubscript{max} and AUC\textsubscript{0-t} for carotegrast
with/without rifampicin was 11724.5 \selectlanguage{ngerman}± 6097.6 vs 2620.1 ± 1843.0 ng
mL\textsuperscript{-1}, and 55046.0 ± 23427.8 vs 9849.9 ± 4580.6 ng h
mL\textsuperscript{-1}, respectively. The ratios (90\% CI) of the
C\textsubscript{max} and AUC\textsubscript{0-t} with/without rifampicin
were 4.78 (3.64 -- 6.29) and 5.59 (4.60 -- 6.79), respectively,
indicating carotegrast has a PK interaction with rifampicin. The
combination with rifampicin also increased the exposure of carotegrast
and its metabolites. The incidence of any AEs with/without rifampicin
was five (25.0\%) and one (5.0\%), respectively. Conclusion:
Coadministration of carotegrast methyl with rifampicin significantly
increased exposure of carotegrast compared with carotegrast methyl
administration alone. However, no increase in the incidence of adverse
drug reactions due to coadministration with rifampicin was observed.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{INTRODUCTION}

Carotegrast methyl (AJM300) is the first orally administrable
small-molecule antagonist of \selectlanguage{greek}α\selectlanguage{english}4-integrin to be approved worldwide for
the induction therapy of ulcerative colitis.\textsuperscript{1} In phase
2 and phase 3 clinical trials,\textsuperscript{2,3} oral administration
of carotegrast methyl 960 mg three times daily after meals for 8 -- 32
weeks effectively induced a clinical response in moderately active
ulcerative colitis patients who had an inadequate response or
intolerance to at least 5-aminosalicylic acid. In these trials,
carotegrast methyl was well tolerated and most adverse drug reactions
were mild or moderate in severity. Although progressive multifocal
leukoencephalopathy (PML) is known to be a fatal adverse drug reaction
to natalizumab,\textsuperscript{4-6} which is a humanized monoclonal
antibody having a mechanism of action similar to that of carotegrast
methyl, no such events related to carotegrast methyl have been reported
so far. In order to reduce the risk of PML, the administration period
should be no longer than 6 months. If the treatment is repeated, a drug
holiday of at least 8 weeks between consecutive administrations is
required.\textsuperscript{7}

Carotegrast methyl is an ester prodrug of carotegrast, which is orally
absorbed and metabolized mainly by carboxylesterase 1 in the liver
rather than in the small intestine to its active metabolite,
carotegrast.\textsuperscript{8} Carotegrast methyl is partly metabolized
by cytochrome P450 (CYP) 3A4 to demethylated carotegrast methyl (M-I)
and then M-II (Figure 1). Carotegrast methyl is mainly excreted in the
feces as carotegrast and its glucuronidate conjugate and excretion in
urine is very limited in healthy adults.\textsuperscript{9}

Ulcerative colitis is a chronic inflammatory disease affecting the
colon, and is a lifelong condition that develops early in
life.\textsuperscript{10-12} Patients treated with carotegrast methyl
may require concomitant medications related to other underlying
conditions. Therefore, it is important to evaluate the potential
drug-drug interactions of carotegrast methyl. In the previous clinical
study, we demonstrated that carotegrast methyl was a moderate inhibitor
of CYP3A4 and that 14-day repeated oral administration increased
exposure to CYP3A4 substrates such as midazolam and atorvastatin,
suggesting that coadministration with carotegrast methyl may enhance the
pharmacological activity of the drugs metabolized by CYP3A4. Carotegrast
was shown to be a substrate for organic anion transporting polypeptide
(OATP)1B1/1B3 in vitro, which is an uptake transporter expressed mainly
in the liver.\textsuperscript{13,14} This suggests that OATP1B1 and
OATP1B3 may be involved in the uptake process of carotegrast in the
human liver, and OATP1B1/1B3 inhibitors may increase the plasma
carotegrast concentration by escaping hepatic metabolism and entering
systemic circulation. Here, we report the results of a clinical study to
evaluate the effects of rifampicin, a potent OATPs inhibitor, on the
pharmacokinetics (PK) and safety of carotegrast methyl in healthy
volunteers.

\textbf{METHODS}

\textbf{Study population}

Subjects were Japanese males aged between 20 and 46 years, with a body
mass index between [?] 18.5 and \textless{} 25.0 kg m\textsuperscript{-2
-1}. Eligible subjects had no clinically problematic abnormalities
regarding their medical findings, vital signs, electrocardiogram, and
laboratory tests, and the investigator determined that there were no
problems that would have prevented participation in this study. The
following subjects were excluded: those who had a previous or current
history of functional disorders related to the liver, heart, kidney,
lungs, blood, gastrointestinal tract, or any other disorders that would
preclude their participation; a previous or current history of upper
gastrointestinal disorders; a history of drug allergy; white blood cell
count [?] 4000 \selectlanguage{greek}µ\selectlanguage{english}L\textsuperscript{-1}; neurological symptoms; a previous
or current history of serious infectious diseases, including
opportunistic infections within 1 year prior to administration of the
study drug; ingestion of grapefruit, grapefruit juice or foods
containing these ingredients within 8 days prior to the start of
administration of the study drug; or ingestion of St. John's Wort or
foods containing these ingredients within 15 days prior to the start of
administration of the study drug.

\textbf{Study design}

This was a single-center, single-oral dose, randomized, open-label,
three-step, 2 x 2 crossover phase 1 study conducted in 20 healthy adults
between February and May 2017 in Japan (Figure 2). The study protocol
and the informed consent form were approved by the institutional review
board of Hakata Clinic. All participants gave written informed consent
before initiation of any study-specific procedures. The study was
conducted in accordance with the ethical principles originating in or
derived from the Declaration of Helsinki, and Good Clinical Practice
guidelines.

Twenty subjects were randomized at the study site using medication
numbers in permutated blocks and treatment-sequence assignments, with
half the subjects assigned to each treatment sequence (sequence A and
sequence B). Subjects were admitted to the study center on day -1.
Subjects in sequence A received a single oral dose of carotegrast methyl
960 mg in combination with oral rifampicin 600 mg on the morning of day
1 after overnight fasting (period I). After being discharged on day 2,
they were again admitted to the study center on day 7, and on the
morning of day 8, received a single oral dose of carotegrast methyl 960
mg after overnight fasting (period II). Subjects were discharged on day
9. Follow-up observation was conducted on day 14. The subjects in the
other group (sequence B) received the same treatments but in the
opposite order.

Because of inexperience in terms of systemic exposure and safety when
960 mg of carotegrast methyl is administered in combination with
rifampicin, we decided to adopt sentinel dosing administration. This
began with a small number of patients (two subjects) as Step 1, and
sequentially moving to Step 2 (four subjects) and Step 3 (remaining 14
subjects) while confirming safety and evaluating PK at each step.
Transition from Step 1 to Step 2, and Step 2 to Step 3 was determined
based on the absence of the following safety criteria; (1) the same
moderate or severe AEs in more than 50\% of the subjects, (2) a serious
AE (SAE), or (3) neurological symptoms suggestive of PML that could not
be ruled out as having a causal relationship with the study drug during
the period between the first dose of Period I (day 1) and two days after
Period II (day 9) in each step. The medical advisor assessed the
validity of the investigator's decision of moving to the next step,
taking into consideration the PK results. The safety committee provided
advice to the clinical trial sponsor from a third-party perspective,
based on professional expertise, in order to ensure safety regarding the
potential for PML to occur.

The Pharmaceuticals and Medical Devices Agency\begin{CJK}{UTF8}{gbsn}　\end{CJK}\selectlanguage{english}\emph{Guideline on drug
interaction for drug development and appropriate provision of
information} recommends that rifampicin or cyclosporine should be
considered for evaluating drug-drug interactions in humans if the study
drug is a substrate of OATP1B1 and
OATP1B3.\textsuperscript{15}Rifampicin was selected as a potent
inhibitor of OATP1B1 and OATP1B3 in this study since cyclosporine has
been reported to inhibit P-glycoprotein in the gastrointestinal
tract\textsuperscript{16} and carotegrast methyl was shown to be a
substrate for P-glycoprotein (data not shown). The guideline
recommends\textsuperscript{15} that the dose of inhibitors used in
clinical drug interaction studies should be a dose that maximizes the
likelihood of a drug interaction being exhibited; therefore, the dose of
rifampicin was set at 600 mg. The dose of carotegrast methyl was set at
960 mg, which was the maximum dose used in healthy adults and patients
with moderately active ulcerative colitis in previous studies, and this
dose was safe and well tolerated.\textsuperscript{3,8,9,17}

Two treatment periods were separated by a 7-day washout period based on
more than five times the terminal elimination half-life
(t\textsubscript{1/2}) of carotegrast methyl and carotegrast, which were
approximately 8.0 -- 20.2 h and 10.0 -- 15.6 h, respectively, when 960
mg of carotegrast methyl was orally administered in healthy adults. The
t\textsubscript{1/2} of rifampicin 450 mg was 2.3
h.\textsuperscript{18}Following this washout period, subjects returned
to the study center for the next treatment.

\textbf{Sample collection, analytical methods, and pharmacokinetic
analysis}

Blood samples were collected for PK analysis of carotegrast methyl,
carotegrast, and other metabolites including M-I, M-II, and carotegrast
glucuronide (carotegrast-gluc) at 0, 0.5, 1, 2, 4, 6, 8, 10, 12, 15, and
24 h post-dose on days 1 and 7. A blood sample was collected on day 14
when subjects visited for follow-up observation. Plasma concentrations
of carotegrast methyl, carotegrast, M-I, M-II, and carotegrast-gluc were
measured by validated methods using liquid chromatography-tandem mass
spectrometry at Toray Research Center, Inc. (Tokyo, Japan). The linear
analytical ranges of carotegrast methyl and its metabolites including
carotegrast, M-I, and M-II were 0.5 - 500 ng mL\textsuperscript{-1}, and
that of carotegrast-gluc was 2.0 - 200 ng mL\textsuperscript{-1}. Plasma
concentrations of rifampicin were not measured in this study.

The primary PK parameters analyzed for carotegrast methyl and its
metabolites included area under the time concentration curve (AUC) from
time of dosing to time of last measurable concentration
(AUC\textsubscript{0-t}), AUC from time of dosing to infinity
(AUC\textsubscript{0-inf}), maximum drug concentration
(C\textsubscript{max}), time to
C\textsubscript{max}(T\textsubscript{max}), t\textsubscript{1/2}, and
mean residence time from time of dosing to time of last measurable
concentration (MRT\textsubscript{0-t}).

\textbf{Safety assessments}

Safety and tolerability were assessed by monitoring the incidence,
nature, and severity of AEs as well as by vital sign measurements,
12-lead electrocardiograms, clinical laboratory testing (hematology,
chemistry, and urinalysis), and physical examinations.

\textbf{Data analysis and statistical analysis}

The sample size was calculated using the coefficient of variations (AUC:
43.7\% and C\textsubscript{max}: 46.8\%) derived from the
C\textsubscript{max} and AUC of carotegrast after oral administration of
carotegrast methyl.\textsuperscript{17} The correlation coefficient was
assumed to be 0.7. When the point estimate of the geometric mean ratio
of the PK parameters of carotegrast methyl obtained in the absence and
presence of rifampicin was set to 1, indicating no drug interaction, the
number of subjects required to have a 90\% confidence interval (CI) of
0.8 -- 1.25 was calculated to be 19 for AUC and 21 for
C\textsubscript{max} with 80\% power. Considering the feasibility of
conducting the trial at the study site, the number of subjects was set
to 20.

The PK parameters were assessed in all subjects who received carotegrast
methyl and whose PK data were adequate for the calculation of [?] 1
primary PK parameter (the PK analysis set). Safety was assessed in all
subjects who received the study drug (the safety analysis set). Levels
of analyte below the level of quantification were entered as 0 for
calculations. Descriptive statistics were used to summarize demographics
and safety parameters. The PK parameters of carotegrast methyl,
carotegrast, M-I, M-II, and carotegrast-gluc were calculated based on
the plasma drug concentration data from subjects who received
carotegrast methyl alone or in combination with rifampicin using
non-compartmental analysis. For plasma drug concentration and PK
parameters, descriptive statistics and the two-sided 95\% CIs were
calculated. A natural logarithmic transformation of PK parameters except
for T\textsubscript{max} was applied for all statistical inference. The
90\% CI for ratios of geometric means of logarithmic PK parameters was
calculated by the following mixed effects model;

Log\textsubscript{e} (PK Parameter) = \selectlanguage{greek}μ \selectlanguage{english}+ group + sequence + time point
+ subject + \selectlanguage{greek}ε

μ: \selectlanguage{english}population mean, time point: duration of administration, subject:
interindividual variation, \selectlanguage{greek}ε: \selectlanguage{english}error

The geometric mean ratios and their 90\% CI for the
AUC\textsubscript{0-t} and C\textsubscript{max} of carotegrast methyl
and carotegrast when carotegrast methyl was administered in combination
with rifampicin versus when carotegrast methyl was administered alone
were calculated. When the 90\% CI of the geometric mean ratio of both
parameters fell within the range of 0.80 -- 1.25, it was determined that
there was no PK interaction. The same analysis was performed for the
other metabolites including M-I, M-II and carotegrast-gluc and for other
PK parameters including T\textsubscript{max}, t\textsubscript{1/2}, and
MRT\textsubscript{0-t} as a reference. For T\textsubscript{max}, a
nonparametric test was performed. PK parameters were calculated using
noncompartmental analysis with WinNonlin Professional Version 6.3
(Phoenix Corporation, Mountain View, California, USA). AEs were coded
using the Medical Dictionary for Regulatory Activities (MedDRA) version
20.0. All data processing, summarization, and analyses were conducted
using SAS software ver. 9.3 for Windows (SAS Institute Inc., Cary, NC,
USA).

\textbf{RESULTS}

Among a total of 66 subjects who gave informed consent, 20 subjects were
randomly assigned to sequence A (n = 10) or sequence B (n = 10). All
subjects received the study drugs in period I and period II (Figure 2).
Baseline demographics were generally similar across all treatment groups
(Table 1). There were no exclusions from the analysis, and all 20
subjects were included in the PK analysis set and safety analysis set.
Twenty subjects received carotegrast methyl alone, and carotegrast
methyl and rifampicin in combination. Plasma drug concentration profiles
of carotegrast methyl, carotegrast, M-I, M-II and carotegrast-gluc after
single oral administration of carotegrast methyl in the presence and
absence of rifampicin under fasting conditions are shown in Figure 3.
The PK parameters are shown in Table 2. Drug-drug interactions between
carotegrast methyl and its metabolites, and rifampicin are shown in
Table 3.

\emph{Carotegrast methyl}

The mean \selectlanguage{ngerman}± standard deviation (SD) of C\textsubscript{max} and
AUC\textsubscript{0-t} for carotegrast with/without rifampicin was
11724.5 ± 6097.6 vs 2620.1 ± 1843.0 ng mL\textsuperscript{-1}, and
55046.0 ± 23427.8 vs 9849.9 ± 4580.6 ng h mL\textsuperscript{-1},
respectively. The geometric mean (95\% CI) ± standard deviation (SD) of
C\textsubscript{max} of carotegrast methyl after a single oral
administration of carotegrast methyl alone and in combination with
rifampicin was 803.4 (572.7, 1126.9) ng mL\textsuperscript{-1} and
1670.4 (1252.7, 2227.3) and ng h mL\textsuperscript{-1}, respectively.
The AUC\textsubscript{0-t} was 2199.1 (1674.1, 2888.7) and 4450.1
(3432.7, 5769.1) ng h mL\textsuperscript{-1}, respectively.

The C\textsubscript{max} and AUC of carotegrast methyl were
approximately doubled by coadministration with rifampicin with a
statistically significant difference between the treatments (\emph{p} =
0.0005 and 0.0004, respectively). The median (min -- max)
T\textsubscript{max} of carotegrast methyl in the absence and presence
of rifampicin was 1.0 (0.5 -- 4.0) and 2.0 (0.5 -- 4.0) h, respectively,
and tended to be delayed by coadministration with rifampicin. The
geometric mean (95\% CI) t\textsubscript{1/2} of carotegrast methyl
after administration of carotegrast methyl alone and in combination with
rifampicin was 2.8 (2.2, 3.5) h and 3.7 (3.1, 4.4) h, respectively. The
geometric mean (95\% CI) MRT\textsubscript{0-t} of carotegrast methyl
after administration of carotegrast methyl alone and in combination with
rifampicin was 2.2 (1.9, 2.5) h and 2.3 (2.1, 2.6) h, respectively, with
no significant difference between the treatments.

\emph{Carotegrast}

Carotegrast was the main active metabolite of carotegrast methyl, and
its mean ± SD of C\textsubscript{max} and AUC were more than double
those of carotegrast methyl (1047.8 ± 846.8 vs 2620.1 ± 1843.0 ng
mL\textsuperscript{-1}, 2583.0 ± 1522.9 vs 9849.9 ± 4580.6 ng h
mL\textsuperscript{-1}, respectively). The geometric mean (95\% CI)
C\textsubscript{max} of carotegrast increased approximately 4.8-fold
from 2170.1 (1629.8, 2889.4) and 10380.6 (8133.2, 13249.0) ng
mL\textsuperscript{-1} by coadministration of carotegrast methyl with
rifampicin (\emph{p} \textless{} 0.0001). Similarly, a 5.6-hold increase
was observed in the geometric mean (95\% CI) AUC\textsubscript{0-t} from
9051.3 (7477.7, 10956.1) and 50548.0 (41286.2, 61887.5) ng h
mL\textsuperscript{-1} (\emph{p} \textless{} 0.0001). The median (min --
max) T\textsubscript{max} of carotegrast after carotegrast methyl
administration without/with rifampicin was 2.0 (1.0 -- 4.0) h and 4.0
(2.0 -- 4.0) h, respectively, which was statistically significant
(\emph{p} = 0.0020), indicating delayed absorption with coadministration
of rifampicin. The geometric mean (95\% CI) t\textsubscript{1/2} was 6.6
(4.9, 8.8) h and 4.9 (4.2, 5.8) h, respectively, indicating a tendency
to decrease with coadministration of rifampicin. The geometric mean
(95\% CI) MRT\textsubscript{0-t} was 4.6 (4.1, 5.2) h and 5.2 (4.9, 5.6)
h, respectively, indicating an increase with coadministration of
rifampicin (\emph{p} = 0.0164). For the other metabolites, M-I and M-II,
the C\textsubscript{max} and AUC\textsubscript{0-t} similarly increased
as a result of the combination with rifampicin. Only the
AUC\textsubscript{0-t} of carotegrast-gluc increased by coadministration
with rifampicin and disappearance took longer than the others.

\emph{Drug interaction of carotegrast methyl with rifampicin}

The geometric mean ratio (90\% CI) of the C\textsubscript{max} and
AUC\textsubscript{0-t} of carotegrast methyl with coadministration of
carotegrast methyl with rifampicin to that of carotegrast methyl alone
was 2.08 (1.54 -- 2.80) and 2.02 (1.53 -- 2.67), respectively. The
geometric mean ratios of the t\textsubscript{1/2} and
MRT\textsubscript{0-t} considered as reference parameters were 1.35
(1.12 -- 1.63) and 1.05 (0.98 -- 1.14), respectively. For the
T\textsubscript{max}, Wilcoxon's signed-rank test did not show a
significant difference (\emph{p} = 0.2847) between carotegrast methyl
with/without rifampicin.

The geometric mean ratio (90\% CI) of the C\textsubscript{max} and
AUC\textsubscript{0-t} of carotegrast with coadministration of
carotegrast methyl with rifampicin to that of carotegrast methyl alone
was 4.78 (3.64 -- 6.29) and 5.59 (4.60 -- 6.79), respectively. The
geometric mean ratios (90\% CI) of the t\textsubscript{1/2} and
MRT\textsubscript{0-t} considered as reference parameters were 0.75
(0.58 -- 0.97) and 1.13 (1.04 -- 1.22), respectively. The median
T\textsubscript{max}of carotegrast was extended from two to four hours
by the coadministration with rifampicin (Wilcoxon signed test, \emph{p}
= 0.0020). Regarding M-I and M-II, the geometric mean ratios (90\% CI)
of the C\textsubscript{max} after coadministration of carotegrast methyl
with rifampicin to that of carotegrast methyl alone were 1.42 (1.15 --
1.75) and 3.57 (2.91 -- 4.38), respectively, and those of the
AUC\textsubscript{0-t} were 1.58 (1.30 -- 1.92) and 6.05 (5.13 -- 7.14),
respectively. PK parameters of carotegrast-gluc were used as a reference
because they deviated from the standards of incurred sample reanalysis.
However, the geometric mean ratios (90\% CI) of the
AUC\textsubscript{0-t} of carotegrast-gluc after coadministration of
carotegrast methyl with rifampicin to that of carotegrast methyl alone
was 1.14 (0.99 -- 1.30).

\emph{Safety}

The incidence of any AEs observed in the carotegrast methyl alone group
was one out \begin{CJK}{UTF8}{gbsn}　\end{CJK}\selectlanguage{english}of 20 (5.0\%), and in the coadministration of carotegrast
methyl with rifampicin group the incidence was five out of 20 (25.0\%).
The incidence of AEs for which a causal relationship with the study drug
could not be ruled out was one out of 20 (5.0\%) in the carotegrast
methyl alone group and one out of 20 (5.0\%) in the rifampicin
combination group. AEs in the coadministration group with rifampicin for
which a causal relationship with concomitant drug could not be ruled out
occurred in two out of 20 subjects (10.0\%). The only AE in the
carotegrast methyl alone group was nausea (one of 20 subjects), while
AEs in the coadministration group with rifampicin were blood bilirubin
increased (two of 20 subjects), C-reactive protein increased (two of 20
subjects), and viral upper respiratory tract infection (one of 20
subjects). All AEs were mild in severity. AEs for which a causal
relationship with the study drug could not be ruled out were nausea in
one out of 20 (5.0\%) in the carotegrast methyl alone group and viral
upper respiratory tract infection in one out of 20 (5.0\%) in the
rifampicin combination group. In the coadministration group with
rifampicin, the AE for which a causal relationship with concomitant
drugs could not be ruled out was blood bilirubin increased, which
occurred in two out of 20 subjects (10.0\%). Neither deaths nor the
other SAEs were reported.

\textbf{DISCUSSION}

This 2 x 2 crossover phase 1 clinical study in healthy male adults
demonstrated that coadministration of carotegrast methyl with
rifampicin, a potent OATP1B1/1B3 inhibitor, increased exposure of
carotegrast methyl and carotegrast, the main metabolite of carotegrast
methyl. However, coadministration with rifampicin was shown to be safe
and well tolerated at the dosage evaluated in this study.

Carotegrast methyl is an ester prodrug of carotegrast, which is the main
component of the metabolites in the blood after oral administration. The
geometric mean ratios (90\% CI) of the AUC\textsubscript{0-t} and
C\textsubscript{max} of carotegrast in the presence of rifampicin to
those in the absence of rifampicin were 5.59 (4.60 -- 6.79) and 4.78
(3.64 -- 6.29), respectively. Both 90\% CIs were outside the range of PK
equivalence of 0.80 -- 1.25, suggesting that carotegrast has a PK
interaction with rifampicin. Similarly, the AUC\textsubscript{0-t}and
C\textsubscript{max} of unchanged carotegrast methyl in plasma, and M-I
and M-II increased by coadministration of carotegrast methyl with
rifampicin. The PK profiles of carotegrast methyl and its N-demethyl
form, M-I, and carotegrast and its N-demethyl form, M-II were similar to
each other, and their impact on drug-drug interactions was also
comparable.

Carotegrast is a substrate for hepatic uptake transporters OATP1B1 and
OATP1B3 in vitro;\textsuperscript{1} therefore, inhibition of OATP1B1
and OATP1B3 by rifampicin resulted in escape from hepatic metabolism and
increased systemic exposure. Carotegrast methyl may be involved as a
substrate of OATP1B1 and OATP1B3 in the body, since carotegrast methyl
itself showed inhibitory activity in vitro. Furthermore, the increase in
carotegrast exposure may be partly due to the inhibitory activity of
P-glycoprotein (P-gp) because carotegrast was a weak substrate of P-gp
in in vitro study. It is reported that single-dose rifampicin increased
the exposure of both lenvatinib\textsuperscript{19} and
venetoclax\textsuperscript{20} by inhibiting P-gp.

The dose of 960 mg of carotegrast methyl used in this clinical study was
the highest dose that has been used in clinical studies of carotegrast
methyl to date,\textsuperscript{3,8,9,17} and there is currently no
clinical experience of administration conditions that resulted in even
higher plasma concentrations than those achieved with 960 mg of
carotegrast methyl. However, coadministration of carotegrast methyl with
rifampicin in this study could elucidate previously unexplored areas in
terms of systemic exposure and safety. Therefore, in this study, we
adopted a sentinel dosing regimen starting from a small number of cases
(two subjects) in Step 1, and gradually transitioned to Step 2 (four
subjects) and Step 3 (14 subjects) while confirming safety and
evaluating PK at each step. It should be noted that even
coadministration of carotegrast methyl with rifampicin was safe and well
tolerated at the dose of 960 mg even though systemic exposure increased.
All AEs observed in relation to coadministration were mild, and neither
SAEs nor AEs leading to treatment discontinuation were observed. In the
clinical studies of carotegrast methyl in patients with ulcerative
colitis, some patients received OATP1B1/1B3 inhibitors such as
clarithromycin, atorvastatin, telmisartan, and tacrolimus as a
concomitant medication, but there was no tendency for an increase in the
incidence of AEs and adverse drug reactions due to the
coadministration.\textsuperscript{3} Furthermore, there was no increase
in the incidence of AEs leading to discontinuation of treatment.
However, it should be noted that there are very few examples of
coadministration with an OATP1B1/1B3 inhibitor. Therefore, it is
necessary to collect more information during post-marketing surveillance
on the safety of carotegrast methyl when coadministered with drugs that
inhibit OATP1B1 and OATP1B3.

\par\null

\textbf{CONCLUSION}

Coadministration of carotegrast methyl with rifampicin, a potent OATP1B1
and OATP1B3 inhibitor, significantly increased the exposure of
carotegrast compared with carotegrast methyl administration alone in
healthy adults. The active metabolite carotegrast was classified as a
sensitive substrate of OATP1B1 and OATP1B3, and carotegrast methyl was a
moderate substrate. However, no increase in the incidence of adverse
drug reactions due to coadministration with rifampicin was observed.

\textbf{ACKNOWLEDGEMENTS}

The authors thank all the volunteers and their families. The study was
funded by EA Pharma Co., Ltd. We thank Toray Research Center, Inc.
(Tokyo, Japan) for the PK analysis. We would also like to thank Yuki
Mukaida (EA Pharma Co., Ltd) and PPD-SNBL K. K. for data management and
statistical analysis. Medical writing support for the development of
this manuscript under the direction of the authors was provided by
Tetsuji Asao, PhD (SunFlare Co., Ltd., Tokyo, Japan), which was funded
by EA Pharma Co., Ltd. (Tokyo, Japan) and Kissei Pharmaceutical Co.,
Ltd. (Matsumoto, Japan).

\textbf{REFERENCES}

\begin{enumerate}
\tightlist
\item
  Dhillon S. Carotegrast methyl: First approval. \emph{Drugs} .
  2022;82(9):1011-6. doi: 10.1007/s40265-022-01732-0.
\item
  Yoshimura N, Watanabe M, Motoya S, et al. Safety and efficacy of
  AJM300, an oral antagonist of \selectlanguage{greek}α\selectlanguage{english}4 integrin, in induction therapy for
  patients with active ulcerative colitis. \emph{Gastroenterology} .
  2015;149(7):1775-83.e2. doi: 10.1053/j.gastro.2015.08.044.
\item
  Matsuoka K, Watanabe M, Ohmori T, et al. AJM300 (carotegrast methyl),
  an oral antagonist of \selectlanguage{greek}α\selectlanguage{english}4-integrin, as induction therapy for patients
  with moderately active ulcerative colitis: a multicentre, randomised,
  double-blind, placebo-controlled, phase 3 study. \emph{Lancet
  Gastroenterol Hepatol} . 2022;7(7):648-57. doi:
  10.1016/S2468-1253(22)00022-X.
\item
  Bloomgren G, Richman S, Hotermans C, et al. Risk of
  natalizumab-associated progressive multifocal
  leukoencephalopathy.\emph{N Engl J Med} . 2012;366(20):1870-80. doi:
  10.1056/NEJMoa1107829.
\item
  McGuigan C, Craner M, Guadagno J, et al. Stratification and monitoring
  of natalizumab-associated progressive multifocal leukoencephalopathy
  risk: recommendations from an expert group. \emph{J Neurol Neurosurg
  Psychiatry} . 2016;87(2):117-25. doi: 10.1136/jnnp-2015-311100.
\item
  Williamson EML, Berger JR. Diagnosis and treatment of progressive
  multifocal leukoencephalopathy associated with multiple sclerosis
  therapies. \emph{Neurotherapeutics} . 2017;14(4):961-73. doi:
  10.1007/s13311-017-0570-7.
\item
  Package insert of Carogra\selectlanguage{ngerman}® Tablets.
  https://www.pmda.go.jp/PmdaSearch/iyakuDetail/ResultDataSetPDF/111890\_2399018F1024\_1\_02Japanese.
  Accessed August 20, 2023.
\item
  Fukase H, Kajioka T, Oikawa I, Ikeda N, Furuie H. Food effect on a
  single high dose of carotegrast methyl, an oral antagonist of
  \selectlanguage{greek}α\selectlanguage{english}4-integrin, in healthy male subjects: a randomised,
  placebo-controlled, double-blind study. \emph{Clin Drug Investig} .
  2020;40(3):237-47. doi: 10.1007/s40261-019-00879-1.
\item
  Fukase H, Kajioka T, Oikawa I, Ikeda N, Furuie H. AJM300, a novel oral
  antagonist of \selectlanguage{greek}α\selectlanguage{english}4-integrin, sustains an increase in circulating
  lymphocytes: A randomised controlled trial in healthy male
  subjects.\emph{Br J Clin Pharmacol.} 2020;86(3):591-600. doi:
  10.1111/bcp.14151.
\item
  Ord\selectlanguage{ngerman}ás I, Eckmann L, Talamini M, Baumgart DC, Sandborn WJ. Ulcerative
  colitis. \emph{Lancet} . 2012;380(9853):1606-19. doi:
  10.1016/S0140-6736(12)60150-0.
\item
  Feuerstein JD, Cheifetz AS. Ulcerative colitis: epidemiology,
  diagnosis, and management. \emph{Mayo Clin Proc} .
  2014;89(11):1553-63. doi: 10.1016/j.mayocp.2014.07.002.
\item
  Ungaro R, Mehandru S, Allen PB, Peyrin-Biroulet L, Colombel JF.
  Ulcerative colitis. \emph{Lancet} . 2017;389(10080):1756-70. doi:
  10.1016/S0140-6736(16)32126-2.
\item
  Nigam SK. What do drug transporters really do? \emph{Nat Rev Drug
  Discov} . 2015;14(1):29-44. doi: 10.1038/nrd4461.
\item
  Kalliokoski A, Niemi M. Impact of OATP transporters on
  pharmacokinetics. \emph{Br J Pharmacol} . 2009;158(3):693-705. doi:
  10.1111/j.1476-5381.2009.00430.x.
\item
  Ministry of Health, Labour and Welfare, Guideline on drug interaction
  for drug development and appropriate provision of information.
  https://www.pmda.go.jp/files/000228122.pdf. Accessed April 8, 2023.
\item
  Lown KS, Mayo RR, Leichtman AB, et al. Role of intestinal
  P-glycoprotein (mdr1) in interpatient variation in the oral
  bioavailability of cyclosporine. \emph{Clin Pharmacol Ther} .
  1997;62(3):248-60. doi: 10.1016/S0009-9236(97)90027-8.
\item
  Kambayashi R, Goto A, Izumi-Nakaseko H, et al. Appraisal of ICH
  E14/S7B Q\&As adopted in February 2022 using thorough QT/QTc study
  data for \selectlanguage{greek}α\selectlanguage{english}4-integrin antagonist carotegrast methyl in Japanese healthy
  subjects. \emph{J Pharmacol Sci} . 2022;150(3):191-9. doi:
  10.1016/j.jphs.2022.08.007.
\item
  The package insert of Rifampicin Capsules.
  https://www.pmda.go.jp/PmdaSearch/iyakuDetail/ResultDataSetPDF/430574\_6164001M1216\_1\_15.
  Japanese. Accessed 18 June, 2023.
\item
  Shumaker RC, Aluri J, Fan J, Martinez G, Thompson GA, Ren M. Effect of
  rifampicin on the pharmacokinetics of lenvatinib in healthy
  adults.\emph{Clin Drug Investig} . 2014;34(9):651-9. doi:
  10.1007/s40261-014-0217-y.
\item
  Agarwal SK, Hu B, Chien D, Wong SL, Salem AH. Evaluation of rifampin's
  transporter inhibitory and CYP3A inductive effects on the
  pharmacokinetics of venetoclax, a BCL-2 inhibitor: results of a
  single- and multiple-dose study. \emph{J Clin Pharmacol} .
  2016;56(11):1335-43. doi: 10.1002/jcph.730.
\end{enumerate}

\textbf{FIGURE LEGENDS}

Figure 1 Metabolic map of carotegrast methyl in humans

The metabolic map was generated based on a human mass balance study in
healthy adults.

Figure 2 Study design

Figure 3 Study flow

Figure 4 Time course of mean + standard deviation of plasma
concentration of (A) carotegrast methyl (B) carotegrast, (C) M-I, (D)
M-II, and (E) carotegrast glucuronate (carotegrast gluc) after oral
carotegrast methyl 960 mg administration in the presence (#) and absence
(*) of oral rifampicin 600 mg.

\textbf{TABLE LEGENDS}

Table 1 Subject demographics

Table 2 Pharmacokinetic parameters of carotegrast methyl and its
metabolites

Table 3 Drug-drug interactions between carotegrast methyl and its
metabolites, and rifampicin

\textbf{Table 1 Volunteer demographics}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& Total no. of subjects N = 20 & Sequence A N = 10 & Sequence B N =
10\tabularnewline
\midrule
\endhead
Age (year), median (min, max) & 22.5 (20, 45) & 22.0 (20, 45) & 24.0
(21, 43)\tabularnewline
Weight (kg), mean \selectlanguage{ngerman}± SD & 64.2 \selectlanguage{ngerman}± 6.4 & 64.4 \selectlanguage{ngerman}± 8.2 & 64.1 \selectlanguage{ngerman}±
4.5\tabularnewline
Height (cm), mean ± SD & 173.0 \selectlanguage{ngerman}± 6.8 & 172.2 \selectlanguage{ngerman}± 7.7 & 173.8 \selectlanguage{ngerman}±
6.1\tabularnewline
BMI (kg m\textsuperscript{2 -1}), mean ± SD & 21.6 \selectlanguage{ngerman}± 1.5 & 21.8 \selectlanguage{ngerman}± 1.8 &
21.4 \selectlanguage{ngerman}± 1.3\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{ngerman}

BMI, Body mass index; max, maximum; min, minimum; SD, standard
deviation.

\par\null

\textbf{Table 2 Pharmacokinetic parameters of carotegrast methyl and its
metabolites}\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
& & & & S\_AJM300 & CO\_RIFAMPICIN\tabularnewline
\midrule
\endhead
Carotegrast methyl & C\textsubscript{max} (ng mL\textsuperscript{-1}) &
C\textsubscript{max} (ng mL\textsuperscript{-1}) & Mean \selectlanguage{ngerman}± SD & 1047.8 \selectlanguage{ngerman}±
846.8 & 1973.8 \selectlanguage{ngerman}± 1151.7\tabularnewline
& & & Geometric Mean & 803.4 & 1670.4\tabularnewline
& & & 95\% CI & 572.7, 1126.9 & 1252.7, 2227.3\tabularnewline
& AUC\textsubscript{0-t} (ng h mL\textsuperscript{-1}) &
AUC\textsubscript{0-t} (ng h mL\textsuperscript{-1}) & Mean \selectlanguage{ngerman}± SD &
2583.0 \selectlanguage{ngerman}± 1522.9 & 5087.8 \selectlanguage{ngerman}± 2626.0\tabularnewline
& & & Geometric Mean & 2199.1 & 4450.1\tabularnewline
& & & 95\% CI & 1674.1, 2888.7 & 3432.7, 5769.1\tabularnewline
& T\textsubscript{max} (h) & T\textsubscript{max} (h) & Median (min,
max) & 1.0 (0.5, 4.0) & 2.0 (0.5, 4.0)\tabularnewline
& t\textsubscript{1/2} (h) & t\textsubscript{1/2} (h) & Mean \selectlanguage{ngerman}± SD & 3.1
\selectlanguage{ngerman}± 1.2 & 4.0 \selectlanguage{ngerman}± 1.5\tabularnewline
& & & Geometric Mean & 2.8 & 3.7\tabularnewline
& & & 95\% CI & 2.2, 3.5 & 3.1, 4.4\tabularnewline
& MRT\textsubscript{0-t} (h) & MRT\textsubscript{0-t} (h) & Mean \selectlanguage{ngerman}± SD &
2.3 \selectlanguage{ngerman}± 0.6 & 2.4 \selectlanguage{ngerman}± 0.6\tabularnewline
& & & Geometric Mean & 2.2 & 2.3\tabularnewline
& & & 95\% CI & 1.9, 2.5 & 2.1, 2.6\tabularnewline
Carotegrast & C\textsubscript{max} (ng mL\textsuperscript{-1}) &
C\textsubscript{max} (ng mL\textsuperscript{-1}) & Mean \selectlanguage{ngerman}± SD & 2620.1 \selectlanguage{ngerman}±
1843.0 & 11724.5 \selectlanguage{ngerman}± 6097.6\tabularnewline
& & & Geometric Mean & 2170.1 & 10380.6\tabularnewline
& & & 95\% CI & 1629.8, 2889.4 & 8133.2, 13249.0\tabularnewline
& AUC\textsubscript{0-t} (ng h mL\textsuperscript{-1}) &
AUC\textsubscript{0-t} (ng h mL\textsuperscript{-1}) & Mean \selectlanguage{ngerman}± SD &
9849.9 \selectlanguage{ngerman}± 4580.6 & 55046.0 \selectlanguage{ngerman}± 23427.8\tabularnewline
& & & Geometric Mean & 9051.3 & 50548.0\tabularnewline
& & & 95\% CI & 7477.7, 10956.1 & 41286.2, 61887.5\tabularnewline
& T\textsubscript{max} (h) & T\textsubscript{max} (h) & Median (min,
max) & 2.0 (1.0, 4.0) & 4.0 (2.0, 4.0)\tabularnewline
& t\textsubscript{1/2} (h) & t\textsubscript{1/2} (h) & Mean \selectlanguage{ngerman}± SD & 8.8
\selectlanguage{ngerman}± 11.2 & 5.3 \selectlanguage{ngerman}± 2.8\tabularnewline
& & & Geometric Mean & 6.6 & 4.9\tabularnewline
& & & 95\% CI & 4.9, 8.8 & 4.2, 5.8\tabularnewline
& MRT\textsubscript{0-t} (h) & MRT\textsubscript{0-t} (h) & Mean \selectlanguage{ngerman}± SD &
4.8 \selectlanguage{ngerman}± 1.2 & 5.3 \selectlanguage{ngerman}± 0.8\tabularnewline
& & & Geometric Mean & 4.6 & 5.2\tabularnewline
& & & 95\% CI & 4.1, 5.2 & 4.9, 5.6\tabularnewline
M-I & C\textsubscript{max} (ng mL\textsuperscript{-1}) &
C\textsubscript{max} (ng mL\textsuperscript{-1}) & Mean \selectlanguage{ngerman}± SD & 40.6 \selectlanguage{ngerman}±
30.3 & 50.7 \selectlanguage{ngerman}± 19.7\tabularnewline
& & & Geometric Mean & 33.0 & 46.9\tabularnewline
& & & 95\% CI & 24.5, 44.5 & 38.6, 57.0\tabularnewline
& AUC\textsubscript{0-t} (ng h mL\textsuperscript{-1}) &
AUC\textsubscript{0-t} (ng h mL\textsuperscript{-1}) & Mean \selectlanguage{ngerman}± SD & 85.6
\selectlanguage{ngerman}± 48.7 & 124.2 \selectlanguage{ngerman}± 40.3\tabularnewline
& & & Geometric Mean & 73.7 & 116.5\tabularnewline
& & & 95\% CI & 56.4, 96.3 & 97.0, 139.9\tabularnewline
& T\textsubscript{max} (h) & T\textsubscript{max} (h) & Median (min,
max) & 1.0 (0.5, 2.0) & 1.0 (0.5, 4.0)\tabularnewline
& t\textsubscript{1/2} (h) & t\textsubscript{1/2} (h) & Mean \selectlanguage{ngerman}± SD & 1.1
\selectlanguage{ngerman}± 0.6 & 1.0 \selectlanguage{ngerman}± 0.7\tabularnewline
& & & Geometric Mean & 1.0 & 0.9\tabularnewline
& & & 95\% CI & 0.8, 1.3 & 0.7, 1.1\tabularnewline
& MRT\textsubscript{0-t} (h) & MRT\textsubscript{0-t} (h) & Mean \selectlanguage{ngerman}± SD &
1.8 \selectlanguage{ngerman}± 0.6 & 1.9 \selectlanguage{ngerman}± 0.7\tabularnewline
& & & Geometric Mean & 1.7 & 1.8\tabularnewline
& & & 95\% CI & 1.4, 2.0 & 1.6, 2.1\tabularnewline
M-II & C\textsubscript{max} (ng mL\textsuperscript{-1}) &
C\textsubscript{max} (ng mL\textsuperscript{-1}) & Mean \selectlanguage{ngerman}± SD & 199.9 \selectlanguage{ngerman}±
146.4 & 641.5 \selectlanguage{ngerman}± 218.8\tabularnewline
& & & Geometric Mean & 168.3 & 600.1\tabularnewline
& & & 95\% CI & 130.3, 217.4 & 498.3, 722.7\tabularnewline
& AUC\textsubscript{0-t} (ng h mL\textsuperscript{-1}) &
AUC\textsubscript{0-t} (ng h mL\textsuperscript{-1}) & Mean \selectlanguage{ngerman}± SD & 789.5
\selectlanguage{ngerman}± 367.7 & 4617.6 \selectlanguage{ngerman}± 1387.5\tabularnewline
& & & Geometric Mean & 723.7 & 4378.0\tabularnewline
& & & 95\% CI & 596.6, 877.8 & 3704.5, 5174.0\tabularnewline
& T\textsubscript{max} (h) & T\textsubscript{max} (h) & Median (min,
max) & 2.0 (1.0, 4.0) & 4.0 (2.0, 6.0)\tabularnewline
& t\textsubscript{1/2} (h) & t\textsubscript{1/2} (h) & Mean \selectlanguage{ngerman}± SD & 5.5
\selectlanguage{ngerman}± 1.8 & 3.7 \selectlanguage{ngerman}± 0.6\tabularnewline
& & & Geometric Mean & 5.3 & 3.7\tabularnewline
& & & 95\% CI & 4.6, 6.1 & 3.4, 4.0\tabularnewline
& MRT\textsubscript{0-t} (h) & MRT\textsubscript{0-t} (h) & Mean \selectlanguage{ngerman}± SD &
4.6 \selectlanguage{ngerman}± 0.9 & 6.8 \selectlanguage{ngerman}± 0.8\tabularnewline
& & & Geometric Mean & 4.5 & 6.7\tabularnewline
& & & 95\% CI & 4.1, 5.0 & 6.4, 7.1\tabularnewline
Carotegrast-gluc & Carotegrast-gluc & C\textsubscript{max} (ng
mL\textsuperscript{-1}) & Mean \selectlanguage{ngerman}± SD & 803.7 \selectlanguage{ngerman}± 430.2 & 622.2 \selectlanguage{ngerman}±
243.2\tabularnewline
& & & Geometric Mean & 729.2 & 577.5\tabularnewline
& & & 95\% CI & 597.0, 890.5 & 477.9, 697.8\tabularnewline
& & AUC\textsubscript{0-t} (ng h mL\textsuperscript{-1}) & Mean \selectlanguage{ngerman}± SD &
2998.4 \selectlanguage{ngerman}± 1081.2 & 3414.8 \selectlanguage{ngerman}± 1085.3\tabularnewline
& & & Geometric Mean & 2855.6 & 3243.2\tabularnewline
& & & 95\% CI & 2473.8, 3296.3 & 2766.5, 3802.1\tabularnewline
& & T\textsubscript{max} (h) & Median (min, max) & 2.0 (1.0, 4.0) & 2.0
(1.0, 4.0)\tabularnewline
& & t\textsubscript{1/2} (h) & Mean \selectlanguage{ngerman}± SD & 6.5 \selectlanguage{ngerman}± 2.9 & 6.0 \selectlanguage{ngerman}±
1.6\tabularnewline
& & & Geometric Mean & 6.0 & 5.8\tabularnewline
& & & 95\% CI & 4.8, 7.3 & 5.2, 6.6\tabularnewline
& & MRT\textsubscript{0-t} (h) & Mean \selectlanguage{ngerman}± SD & 4.4 \selectlanguage{ngerman}± 1.0 & 5.8 \selectlanguage{ngerman}±
0.8\tabularnewline
& & & Geometric Mean & 4.3 & 5.7\tabularnewline
& & & 95\% CI & 3.8, 4.7 & 5.4, 6.1\tabularnewline
\bottomrule
\end{longtable}

AUC \textsubscript{0-t}, area under the curve from time 0 to the last
measurable concentration; carotegrast-gluc, carotegrast glucuronate; CI,
confidence interval; C\textsubscript{max}, maximum drug concentration;
CO\_RIFAMPICIN, coadministration with rifampicin (600 mg); max, maximum;
min, minimum; S\_AJM300, single oral administration of carotegrast
methyl (960 mg); SD: standard deviation; t\textsubscript{1/2}, half-life
period; T\textsubscript{max}, time to C\textsubscript{max} maximum drug
concentration

\textbf{Table 3 Drug-drug interactions between carotegrast methyl and
its metabolites, and rifampicin}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
Carotegrast methyl & C\textsubscript{max} (ng mL\textsuperscript{-1}) &
Estimated ratio after inverse logarithmic conversion* &
2.08\tabularnewline
\midrule
\endhead
& & 90\% CI of the ratio & 1.54, 2.80\tabularnewline
& & \emph{p}-value** & 0.0005\tabularnewline
& AUC\textsubscript{0-t} (ng h mL\textsuperscript{-1}) & Estimated ratio
after inverse logarithmic conversion* & 2.02\tabularnewline
& & 90\% CI of the ratio & 1.53, 2.67\tabularnewline
& & \emph{p}-value** & 0.0004\tabularnewline
& T\textsubscript{max} (h) & Median (Min, Max) in carotegrast methyl
alone & 1.0 (0.5, 4.0)\tabularnewline
& & Median (Min, Max) in the combination with rifampicin & 2.0 (0.5,
4.0)\tabularnewline
& & Test statistics & 18.5\tabularnewline
& & \emph{p}-value** & 0.2847\tabularnewline
& t\textsubscript{1/2} (h) & Estimated ratio after inverse logarithmic
conversion* & 1.35\tabularnewline
& & 90\% CI of the ratio & 1.12, 1.63\tabularnewline
& & \emph{p}-value** & 0.0112\tabularnewline
& MRT\textsubscript{0-t} (h) & Estimated ratio after inverse logarithmic
conversion* & 1.05\tabularnewline
& & 90\% CI of the ratio & 0.98, 1.14\tabularnewline
& & \emph{p}-value** & 0.2594\tabularnewline
Carotegrast & C\textsubscript{max} (ng mL\textsuperscript{-1}) &
Estimated ratio after inverse logarithmic conversion* &
4.78\tabularnewline
& & 90\% CI of the ratio & 3.64, 6.29\tabularnewline
& & \emph{p}-value** & \textless{}.0001\tabularnewline
& AUC\textsubscript{0-t} (ng h mL\textsuperscript{-1}) & Estimated ratio
after inverse logarithmic conversion* & 5.59\tabularnewline
& & 90\% CI of the ratio & 4.60, 6.79\tabularnewline
& & \emph{p}-value** & \textless{}.0001\tabularnewline
& T\textsubscript{max} (h) & Median (Min, Max) in carotegrast methyl
alone & 2.0 (1.0, 4.0)\tabularnewline
& & Median (Min, Max) in the combination with rifampicin & 4.0 (2.0,
4.0)\tabularnewline
& & Test statistics & 27.5\tabularnewline
& & \emph{p}-value** & 0.0020\tabularnewline
& t\textsubscript{1/2} (h) & Estimated ratio after inverse logarithmic
conversion* & 0.75\tabularnewline
& & 90\% CI of the ratio & 0.58, 0.97\tabularnewline
& & \emph{p}-value** & 0.0677\tabularnewline
& MRT\textsubscript{0-t} (h) & Estimated ratio after inverse logarithmic
conversion* & 1.13\tabularnewline
& & 90\% CI of the ratio & 1.04, 1.22\tabularnewline
& & \emph{p}-value** & 0.0164\tabularnewline
M-I & C\textsubscript{max} (ng mL\textsuperscript{-1}) & Estimated ratio
after inverse logarithmic conversion* & 1.42\tabularnewline
& & 90\% CI of the ratio & 1.15, 1.75\tabularnewline
& & \emph{p}-value** & 0.0094\tabularnewline
& AUC\textsubscript{0-t} (ng h mL\textsuperscript{-1}) & Estimated ratio
after inverse logarithmic conversion* & 1.58\tabularnewline
& & 90\% CI of the ratio & 1.30, 1.92\tabularnewline
& & \emph{p}-value** & 0.0007\tabularnewline
& T\textsubscript{max} (h) & Median (Min, Max) in carotegrast methyl
alone & 1.0 (0.5, 2.0)\tabularnewline
& & Median (Min, Max) in the combination with rifampicin & 1.0 (0.5,
4.0)\tabularnewline
& & Test statistics & 37.0\tabularnewline
& & \emph{p}-value** & 0.0348\tabularnewline
& t\textsubscript{1/2} (h) & Estimated ratio after inverse logarithmic
conversion* & 0.89\tabularnewline
& & 90\% CI of the ratio & 0.70, 1.13\tabularnewline
& & \emph{p}-value** & 0.3877\tabularnewline
& MRT\textsubscript{0-t} (h) & Estimated ratio after inverse logarithmic
conversion* & 1.09\tabularnewline
& & 90\% CI of the ratio & 1.01, 1.19\tabularnewline
& & \emph{p}-value** & 0.0750\tabularnewline
M-II & C\textsubscript{max} (ng mL\textsuperscript{-1}) & Estimated
ratio after inverse logarithmic conversion* & 3.57\tabularnewline
& & 90\% CI of the ratio & 2.91, 4.38\tabularnewline
& & \emph{p}-value** & \textless{}.0001\tabularnewline
& AUC\textsubscript{0-t} (ng h mL\textsuperscript{-1}) & Estimated ratio
after inverse logarithmic conversion* & 6.05\tabularnewline
& & 90\% CI of the ratio & 5.13, 7.14\tabularnewline
& & \emph{p}-value** & \textless{}.0001\tabularnewline
& T\textsubscript{max} (h) & Median (Min, Max) in carotegrast methyl
alone & 2.0 (1.0, 4.0)\tabularnewline
& & Median (Min, Max) in the combination with rifampicin & 4.0 (2.0,
6.0)\tabularnewline
& & Test statistics & 51.5\tabularnewline
& & \emph{p}-value** & 0.0010\tabularnewline
& t\textsubscript{1/2} (h) & Estimated ratio after inverse logarithmic
conversion* & 0.70\tabularnewline
& & 90\% CI of the ratio & 0.63, 0.78\tabularnewline
& & \emph{p}-value (Treatment Group) & \textless{}.0001\tabularnewline
& MRT\textsubscript{0-t} (h) & Estimated ratio after inverse logarithmic
conversion & 1.49\tabularnewline
& & 90\% CI of the ratio & 1.41, 1.57\tabularnewline
& & \emph{p}-value** & \textless{}.0001\tabularnewline
Carotegrast-glu & C\textsubscript{max} (ng mL\textsuperscript{-1}) &
Estimated ratio after inverse logarithmic conversion* &
0.79\tabularnewline
& & 90\% CI of the ratio & 0.67, 0.94\tabularnewline
& & \emph{p}-value** & 0.0272\tabularnewline
& AUC\textsubscript{0-t} (ng h mL\textsuperscript{-1}) & Estimated ratio
after inverse logarithmic conversion* & 1.14\tabularnewline
& & 90\% CI of the ratio & 0.99, 1.30\tabularnewline
& & \emph{p}-value** & 0.1158\tabularnewline
& T\textsubscript{max} (h) & Median (Min, Max) in carotegrast methyl
alone & 2.0 (1.0, 4.0)\tabularnewline
& & Median (Min, Max) in the combination with rifampicin & 2.0 (1.0,
4.0)\tabularnewline
& & Test statistics & 11.0\tabularnewline
& & \emph{p}-value** & 0.1719\tabularnewline
& t\textsubscript{1/2} (h) & Estimated ratio after inverse logarithmic
conversion* & 0.98\tabularnewline
& & 90\% CI of the ratio & 0.84, 1.14\tabularnewline
& & \emph{p}-value (Treatment Group) & 0.7938\tabularnewline
& MRT\textsubscript{0-t} (h) & Estimated ratio after inverse logarithmic
conversion & 1.35\tabularnewline
& & 90\% CI of the ratio & 1.26, 1.44\tabularnewline
& & \emph{p}-value** & \textless{}.0001\tabularnewline
\bottomrule
\end{longtable}

* The ratio was with/without rifampicin. ** Between the carotegrast
methyl alone group and coadministration of carotegrast methyl with
rifampicin

AUC \textsubscript{0-t}, area under the curve from time 0 to the last
measurable concentration; carotegrast-gluc, carotegrast glucuronate; CI,
confidence interval; C\textsubscript{max}, maximum drug concentration;
max, maximum; min, minimum; t\textsubscript{1/2}, half-life period;
T\textsubscript{max}, time to C\textsubscript{max} maximum drug
concentration

\textbf{Hosted file}

\verb`AJM300_CP8_Figure-1.docx`  available at \url{https://authorea.com/users/669495/articles/669932-effects-of-rifampicin-on-the-pharmacokinetics-and-safety-of-carotegrast-methyl-in-healthy-subjects-a-randomized-2-x-2-crossover-study}

\textbf{Hosted file}

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\textbf{Hosted file}

\verb`AJM300_CP8_Figure-3.docx`  available at \url{https://authorea.com/users/669495/articles/669932-effects-of-rifampicin-on-the-pharmacokinetics-and-safety-of-carotegrast-methyl-in-healthy-subjects-a-randomized-2-x-2-crossover-study}

\textbf{Hosted file}

\verb`AJM300_CP8_Figure-4.docx`  available at \url{https://authorea.com/users/669495/articles/669932-effects-of-rifampicin-on-the-pharmacokinetics-and-safety-of-carotegrast-methyl-in-healthy-subjects-a-randomized-2-x-2-crossover-study}

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