Oral bioavailability refers to the extent a substance or drug becomes completely available to systemic circulation or to its intended biological destination(s) via the oral route [1]. High oral bioavailability reduces the amount of a drug necessary to achieve a desired pharmacological effect, therefore reducing the risk of side-effects and toxicity. Low oral bioavailability results in low efficacy and is a major reason for drug candidates failing to reach the market. Hence, oral bioavailability is one of the most important properties in drug design and development.

Critical determinants of oral bioavailability include the gastrointestinal (GI) tract physiology, hepatic first-pass metabolism, plasma protein binding and excretion via the kidneys. In the GI tract, the intestinal epithelium crucially contributes to oral bioavailability by constituting an important site for drug absorption, distribution, metabolism, and excretion (ADME). Exposed to high concentrations of food-borne, microbiota-derived, or other exogenous xenobiotics, including toxins and carcinogens, intestinal epithelial cells (IEC) are trained to defend themselves and the body from harmful substances. Hence, expression of enzymes and transporters involved in drug metabolism and xenobiotic defense including cytochrome P450 isoenzymes (CYPs), UDP-glucuronosyltransferase isoforms (UGTs) and ATP binding cassette (ABC) transporters, e.g., the multidrug efflux pump P-glycoprotein (P-gp), give rise to the concept of the intestinal epithelium as a pharmacogenetic barrier [2]. Additionally, the inert function of enterocytes, the subtype of IECs specialized in uptake processes, to absorb nutrients, contributes to oral bioavailability of drugs. For example, certain inhibitors of angiotensin-converting enzyme, protease inhibitors, antivirals, and peptidomimetics like β-lactam antibiotics are absorbed by the peptide transporter 1 (PEPT1) [3]. The main route of orally administered drugs into the systemic circulation is by direct passage from the IEC layer into the mesenteric blood capillaries, yet certain drugs gain access to the systemic circulation via intestinal lymphatic absorption. Following this pathway, absorbed drugs associate with fats and lipoproteins within IECs as they are processed into chylomicrons. [4]. Vice versa, enterocyte fatty acid oxidation (FAO), which has been implicated in the in the control of eating, can be pharmacologically modified ^[5][6][5,6]. Consequently, intestinal transport processes, IEC metabolism and their interconnection to whole-body metabolic state are relevant to a variety of diseases and represent potential therapeutic targets. Next to intestinal pathologies like malabsorption syndromes or inflammatory diseases, these pathologies comprise metabolic disorders such as obesity and type 2 diabetes, and additionally, diseases treated with drugs and prodrugs that are actively absorbed and/or metabolized by enterocytes. Thus, beyond constituting a physical barrier separating the host from its environment including the intestinal microbiota, IECs actively serve as gatekeepers of nutrient availability and metabolic health for the whole organism.

Despite this importance, many aspects of nutrient absorption, enterocyte metabolism, and drug bioavailability are still unknown, e.g., the underlying causes of fructose malabsorption remain elusive [7]. Hence, there is a need for advanced model systems that enable studying intestinal transport processes and IEC metabolism, especially in the context of drug development. Commonly used in vitro models of the intestinal epithelium, such as Caco-2 cells or rodent explant models (Ussing chamber, everted gut sac models) are of limited value due to their cancer and non-human origin, respectively. In particular, species differences result in poorly correlative data, and findings obtained in these models cannot be translated reliably to humans. Contrarily, human intestinal organoids allow investigating different aspects of oral bioavailability, form inter-individual differences to broad uptake screenings, thus representing a superior model of the intestinal epithelium. Intestinal organoid lines created from biopsies of healthy and diseased individuals [8] can be readily expanded and maintain their region-specific expression patterns upon differentiation. Functional characteristics including absorption studies and metabolomics have already been conducted on three-dimensional organoids derived from human small and large intestinal biopsies [9]. Cultured in 2D on trans-well membranes, organoid-derived cell lawns provide a valuable tool to study drug permeability in spatial resolution as well as inter-individual differences. Of note, intestinal organoids not only enable measurement of intestinal transport and intracellular (drug-) metabolism in a dynamic way, downstream events like molecular signalling pathways resulting in hormone secretion can be investigated in parallel [10].

Several countries have already developed strategic roadmaps to phase out animal experiments for regulatory purposes. This increases the need for a timely substitute that reflects physiology in the best possible manner. Intestinal organoid culture and organ-on-a-chip technology are promising ways forward in the preclinical and regulatory setup and will aid implementing the 3Rs (reduction, refinement and replacement) principle in basic science.

3. Future Directions

MPS and organoid models can be combined with in silico approaches, complex computer-based models that precisely predict ADME processes and pharmacokinetics in pharmaceutical and toxicological research ^[11][193]. It has been proven that in silico approaches even provide a better predictability in toxicology testing compared to animal experiments ^[12][13][194,195]. Computational methods can also be used as alternatives to animal testing in safety and efficacy testing such as Quantitative Structure–Activity Relationship (QSAR) modelling and physiologically based kinetic and dynamic modelling. QSAR models predict biological and toxicological effects of drugs and other chemicals based on their physicochemical and structural properties. Chemical properties can also be predicted by “read-across”, grouping of chemicals on the basis of structural and biological similarity. Read-across is typically carried out in addition to QSAR, to increase the overall confidence in the predicted properties. Complementary, PBK models predict the distribution of a drug or chemical in a living organism. PKB models are used to interpret in vitro toxicity data simulating internal concentrations following exposure to the chemical via the diet, skin or inhalation. Coupling PBK with other mathematical models describing biological responses in a specific organ is called physiologically based kinetic and dynamic (PBKD) modelling. The virtual cell-based assay (VCBA) is a mathematical model developed by the JRC ^[14][196]. It simulates the distribution and biological effects of chemicals in a range of in vitro systems. Integrated approaches combining computational modelling, human studies and human-based in vitro models, such as advanced cell cultures or MPS will improve human safety assessment and accelerate medical development.

4. Conclusions

There is no doubt that human-based model systems are needed to produce human-relevant data for medical, pharmacological or toxicological purposes. High failure rates within the drug development pipeline constitute a problem increasingly recognised and targeted by the scientific community including academia, industry and regulatory bodies ^{[15][16][17][18][19]}[197,198,199,200,201]. Failure rates calculated based on statistical analyses of drug approvals in a certain time frame account to as much as 95% ^[20][21][22][117,127,129], with oncology, neurology and cardiovascular diseases displaying the worst results ^[22][129]. To a large extent, this failure which occurs mainly in safety and efficacy testing, can be attributed to a lack of transferability of preclinical data including animal experiments to the human trials. Computational approaches together with advanced in vitro models complemented by human clinical and epidemiological studies offer a research portfolio that is capable of reliably investigating human-relevant issues related to health and disease. We are on a good way having human-based techniques available that provide excellent tools to study drug bioavailability and other pharmaceutical issues in a human-relevant manner.