Selective inhibition of warfarin metabolism by diltiazem in humans

Healthy men were administered i.v. racemic warfarin, S-warfarin or R-warfarin on two occasions, once in the drug-free state and once during concomitant administration of oral diltiazem 120 mg three times daily. Blood samples for determination of plasma warfarin and diltiazem concentrations, the prothrombin time and complete urine collections were obtained for determination of urinary excretion of dehydrowarfarin, 4'-hydroxywarfarin, 6-hydroxywarfarin, 7-hydroxywarfarin, 8-hydroxywarfarin and unchanged parent drug for 216 h after each dose. Concurrent diltiazem administration decreased total racemic warfarin clearance (+/- S.D.) [3.60 +/- 0.99 (control) versus 3.19 +/- 0.86 (diltiazem) ml/min; P less than .05]. Disposition of the more potent anticoagulant S-warfarin was not altered by diltiazem treatment. In contrast total clearance of R-warfarin was decreased [3.47 +/- 1.10 (control) versus 2.77 +/- 0.92 ml/min; P less than .05]. No change in the area under the prothrombin time versus time after warfarin administration curve was associated with diltiazem treatment for any warfarin trial. Inhibition of R-warfarin by diltiazem was regioselective for metabolites as determined by fractional clearance of urinary metabolites. R-6-hydroxywarfarin clearance (+/- S.E.) [29.5 +/- 7.2 (control) versus 15.7 +/- 2.8 ml/h; P less than 0.05] and R-8-hydroxywarfarin clearance [21.1 +/- 3.6 (control) versus 11.2 +/- 2.0 ml/h; P less than .05] were selectively decreased with no significant change in the urinary clearance of R-dehydro, R-4-hydroxy and R-7-hydroxywarfarin. Urinary clearance of unchanged R-warfarin was also decreased during diltiazem administration. Diltiazem inhibits warfarin disposition in humans in a stereospecific and regiospecific manner.