Comprehensive kinetic and modeling analyses revealed CYP2C9 and 3A4 determine terbinafine metabolic clearance and...

Terbinafine N-dealkylation pathways result in formation of 6,6-dimethyl-2-hepten-4-ynal (TBF-A), a reactive allylic aldehyde, that may initiate idiosyncratic drug-induced liver toxicity. Previously, we reported on the importance of CYP2C19 and 3A4 as major contributors to TBF-A formation. In this study, we expanded on those efforts to assess individual contributions of CYP1A2, 2B6, 2C8, 2C9, and 2D6 in terbinafine metabolism. The combined knowledge gained from these studies allowed us to scale the relative roles of the P450 isozymes in hepatic clearance of terbinafine including pathways leading to TBF-A, and hence, provide a foundation for assessing their significance in terbinafine-induced hepatotoxicity. We used in vitro terbinafine reactions with recombinant P450s to measure kinetics for multiple metabolic pathways and calculated contributions of all individual P450 isozymes to in vivo hepatic clearance for the average human adult. The findings confirmed that CYP3A4 was a major contributor (at least 30% total metabolism) to all three of the possible N-dealkylation pathways; however, CYP2C9, and not CYP2C19, played a critical role in terbinafine metabolism and even exceeded CYP3A4 contributions for terbinafine N-demethylation. A combination of their metabolic capacities accounted for at least 80% of the conversion of terbinafine to TBF-A, while CYP1A2, 2B6, 2C8, and 2D6 made minor contributions. Computational approaches provide a more rapid, less resource-intensive strategy for assessing metabolism, and thus, we additionally predicted terbinafine metabolism using deep neural network models for individual P450 isozymes. Cytochrome P450 isozyme models accurately predicted the likelihood for terbinafine N-demethylation, but overestimated the likelihood for a minor N-denaphthylation pathway. Moreover, the models were not able to differentiate the varying roles of the individual P450 isozymes for specific reactions with this particular drug. Taken together, the significance of CYP2C9 and 3A4 and to a lesser extent, CYP2C19, in terbinafine metabolism is consistent with reported drug interactions. This finding suggests that variations in individual P450 contributions due to other factors like polymorphisms may similarly contribute to terbinafine-related adverse health outcomes. Nevertheless, the impact of their metabolic capacities on formation of reactive TBF-A and consequent idiosyncratic hepatotoxicity will be mitigated by competing detoxification pathways, TBF-A decay, and TBF-A adduction to glutathione that remain understudied.