Explaining clinically important variability in response to simvastatin treatment using a PBPK/PD approach

Understanding exposure‐response relationships is critical for the selection of an optimal drug dose that balances efficacy and safety. For simvastatin (SV), plasma concentrations may not accurately reflect target site exposure, because its pharmacologic effect is linked to intrahepatic unbound concentrations of its active form, simvastatin hydroxy acid (SVA). SVA is taken up into hepatocytes via the OATP1B1 transporter (encoded by SLCO1B1 ), where it is metabolized by CYP3A4. Physiological conditions such as obesity and post‐Roux‐en‐Y gastric bypass (RYGB) surgery can alter drug disposition and enzyme activity, impacting hepatic drug exposure. This study aimed to evaluate gene–drug interaction and disease–drug interactions affecting SVA pharmacokinetics and optimize SV dosing by linking intrahepatic unbound SVA concentration to LDL‐cholesterol (LDL‐C) reduction using a physiologically based pharmacokinetic/pharmacodynamic (PBPK/PD) modeling approach. Simulations across doses, genotypes, and populations revealed that SLCO1B1 c.521T>C variation significantly affects plasma SVA exposure, but not hepatic SVA exposure. Obese individuals exhibited higher plasma and hepatic SVA exposure than non‐obese individuals. A 20 mg dose achieved a 30–49% LDL‐C reduction in obese subjects, regardless of SLCO1B1 genotype, whereas non‐obese subjects may require 40 mg to achieve similar efficacy. In conclusion, systemic drug concentration or genotyping alone are insufficient to predict statin response. Instead, information on genetic and physiological variability needs to be integrated into a PBPK/PD framework to select optimal doses across diverse populations.