CLINICAL PHARMACOLOGY 2003 (PART 9B)

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CLINICAL PHARMACOLOGY 2003 (PART 9B)

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If a drug is administered by constant-rate i.v. infusion it is important to know when steady state has been reached, for maintaining the same dosing schedule will then ensure a constant amount of drug in the body and the patient will experience neither acute toxicity nor decline of effect. The t1/2 provides the answer: with the passage of each t1/2 period of time, the plasma concentration rises by half the difference between the current concentration and the ultimate steady-state (100%) concentration. ...

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7 GENERAL PHARMACOLOGY Time to reach steady state Decline in plasma concentration If a drug is administered by constant-rate i.v. Since t1/2 is the time taken for any plasma con- infusion it is important to know when steady state centration to decline by one-half, starting at any has been reached, for maintaining the same dosing steady-state (100%) plasma concentration, in 1 x t1/2 schedule will then ensure a constant amount of the plasma concentration will fall to 50%, in 2 x t1/2 drug in the body and the patient will experience to 25%, in 3 xt1/2to 12.5%, in 4 xt1/2to 6.25% and in neither acute toxicity nor decline of effect. The t1/2 5 x t1/2 to 3.125% of the original steady-state provides the answer: with the passage of each t1/2 concentration. period of time, the plasma concentration rises by Hence the il/2 can predict the rate and extent of half the difference between the current concentration decline in plasma concentration after dosing is and the ultimate steady-state (100%) concentration. discontinued. The relation between t/£ and time to Thus: reach steady-state plasma concentration applies to all drugs that obey first-order kinetics, as much to in 1 x t1/2, the concentration will reach (100/2) dobutamine (t/£ 2 min) when it is useful to know 50%, that an alteration of infusion rate will reach a in 2 x t1/2 (50 + 50/2) 75%, plateau within 10 min, as to digoxin (il/2 36 h) when in 3 x i\ (75 + 25/2) 87.5%, a constant (repeated) dose will give a steady-state in 4 x ty2 (87.5 + 12.5/2) 93.75% plasma concentration only after 7.5 days. Plasma t1/2 in 5 x i\ (93.75 + 6.25/2) 96.875% of the ultimate values are given in the text where they seem steady state. particularly relevant. Inevitably, natural variation within the population produces a range in tl/2 values When a drug is given at a constant rate (continuous or for any drug. For clarity only, single average t1/2 intermittent) the time to reach steady state depends only values are given while recognising that the population on the t'/2 and, for all practical purposes, after 5 x t'/2 the amount of drug in the body will be constant and the range may be as much as 50% from the stated figure plasma concentration will be at a plateau. in either direction. A few t1/2 values are listed in Table 7.1 so that they can be pondered upon in relation to dosing in clinical practice. Changes in plasma concentration Biological effect t^ is the time in which the The same principle holds for change from any biological effect of a drug declines by one half. With steady-state plasma concentration to a new steady drugs that act competitively on receptors (a- and (3- state brought about by increase or decrease in the adrenoceptor agonists and antagonists) the biological rate of drug administration, provided the kinetics effect t1/2 can be provided with reasonable accuracy. remain first-order. Thus when the rate of admin- istration is altered to cause either a rise or a fall in plasma concentration, a new steady-state concen- tration will eventually be reached and it will take TABLE 7.1 Plasma t'/2 of some drugs a time equal to 5 x tl/2 to reach the new steady Drug t'/2 state. adenosine
TIME COURSE OF DRUG CONCENTRATION AND EFFECT 7 Sometimes the biological effect tl/2 cannot be pro- irreversibly and these have been named 'hit and vided, e.g. with antimicrobials when the number of run drugs' because their effect persists long after infecting organisms and their sensitivity determine the drug has left the plasma. Such drugs destroy or the outcome. inactivate target tissue (enzyme, receptor) and restoration of effect occurs only after days or weeks, when resynthesis takes place, e.g. some monoamine THERAPEUTIC MONITORING oxidase inhibitors, aspirin (on platelets), some The issues that concern the practising doctor are not anticholinesterases and anticancer drugs. primarily those of changing drug plasma concen- tration but relate to drug effect: to the onset, Plasma concentration may correlate poorly with magnitude and duration of action of individual effect. Inflammatory states may cause misleading doses. Accurate information about the time course results if only total drug concentration is measured. of drug action is less readily obtained than that Many basic drugs, e.g. lidocaine, disopyramide, bind about plasma concentration. This immediately raises to acute phase proteins, e.g. o^-acid glycoprotein, implications about the relation between plasma which are present in greatly elevated concentration concentration and drug effect and, particularly, the in inflammatory states. The consequent rise in total extent to which useful response may be predicted drug concentration is due to increase in bound by measuring the concentration of drug in plasma. (inactive) but not in the free (active) concentration Experience shows that patients differ greatly in and correlation with effect will be poor if only total the amount of drug required to achieve the same drug is measured. The best correlation is likely to be response. The dose of warfarin that maintains a achieved by measurement of free (active) drug in therapeutic concentration may vary as much as 5- plasma water but this is technically more difficult fold between individuals, and there are many other and total drug in plasma is usually monitored in examples. This is hardly surprising considering routine clinical practice. known variation in rates of drug metabolism, in The assay procedure may not measure metabolites disposition and in tissue responsiveness, and it of a drug that are pharmacologically active, e.g. raises the question of how optimal drug effect can some benzodiazepines, or may measure metabolites be achieved quickly in each patient, i.e. can drug that are pharmacologically inactive; in either event therapy be individualised? A logical approach is to correlation between plasma concentration and assume that effect is related to drug concentration effect is weakened. at the receptor site in the tissues and that in turn the plasma concentration is likely to be constantly Plasma concentration may correlate well with effect. related to, though not necessarily the same as, tissue When this is the case, and when the therapeutic concentration. Indeed, for many drugs, correlation effect is inconvenient to measure, dosage may best between plasma concentration and clinical effect is be monitored according to the plasma concentration better than that between dose and effect. Yet (in relation to a previously defined optimum range). monitoring therapy by measuring drug in plasma is Plasma concentration monitoring has proved of practical use only in selected instances. The useful in the following situations: reasons for this repay some thought. • As a guide to the effectiveness of therapy, e.g. Plasma concentration may not be worth measuring. plasma gentamicin and other antimicrobials This is the case where dose can be titrated against a against sensitive bacteria, plasma theophylline quickly and easily measured effect such as blood for asthma, blood ciclosporin to avoid transplant pressure (antihypertensives), body weight (diuretics), rejection INR (oral anticoagulants) or blood sugar (hyp- • When the desired effect is suppression of oglycaemics). infrequent sporadic events such as epileptic seizures or episodes of cardiac arrhythmia Plasma concentration has no correlation with • To reduce the risk of adverse drug effects, e.g. effect. This is the case with drugs that act otic damage with aminoglycoside antibiotics or 103
7 GENERAL PHARMACOLOGY adverse CNS effects of lithium, when therapeutic of 50-200 micrograms/1 when the drug is given doses are close to toxic doses (low therapeutic by mouth. index) Recommended plasma concentrations for drugs When lack of therapeutic effect and toxicity may appear throughout this book where these are relevant. be difficult to distinguish. Digoxin is both a treatment for, and sometimes the cause of, cardiac supraventricular tachycardia; a plasma digoxin measurement will help to distinguish whether an arrhythmia is due to too little or too Individual much digoxin pharmacokinetic When there is no quick and reliable assessment of effect, e.g. lithium for mood disorder processes To check patient compliance on a drug regimen, when there is failure of therapeutic effect at a This section considers the processes whereby drugs dose that is expected to be effective, e.g. are absorbed into, distributed around, metabolised antiepilepsy drugs by and eliminated from the body. To diagnose and treat drug overdose. Interpreting plasma concentration Absorption measurements Commonsense considerations of anatomy, physio- The following points are relevant: logy, pathology, pharmacology, therapeutics and • A target therapeutic concentration range quoted convenience determine the routes by which drugs for a drug should be regarded only as a guide to are administered. Usually these are: help to optimise dosing and should be evaluated • Enteral: by mouth (swallowed) or by sublingual with other clinical indicators of progress. or buccal absorption; by rectum • Consider whether a patient has been taking a • Parenteral: by intravenous injection or infusion, drug for a sufficient time to reach steady-state intramuscular injection, subcutaneous injection conditions, i.e. when 5t1/2periods have elapsed or infusion, inhalation, topical application for since dosing commenced or since the last change local (skin, eye, lung) or for systemic in dose. In the case of drugs that alter their own (transdermal) effect rates of metabolism by enzyme induction, e.g. • Other routes, e.g. intrathecal, intradermal, carbamazepine and phenytoin, it is best to allow intranasal, intratracheal, intrapleural, are used 2-4 weeks to elapse between change in dose and when appropriate. plasma concentration measurement. Sampling when plasma concentrations are still rising or The features of the various routes, their advantages falling towards a steady state is likely to be and disadvantages are relevant. misleading. • Consider whether peak or trough concentration ABSORPTION FROM THE should be measured. As a general rule when a GASTROINTESTINAL TRACT drug has a short tl/2 it is desirable to know both; monitoring peak (15 min after an i.v. dose) and The small intestine is the principal site for absorption trough (just before the next dose) concentrations of nutrients and it is also where most orally- of gentamicin(t1/22.5 h) helps to provide efficacy administered drugs enter the body. This part of the without toxicity. For a drug with a longt1/2,it is gut has two important attributes, an enormous usually best to sample just before a dose is due; surface area due to the intestinal villi, and an effective immunosuppression with ciclosporin epithelium through which fluid readily filters in (tl/2 27 h) is obtained with trough concentrations response to osmotic differences caused by the 104
ABSORPTION 7 presence of food. It follows that drug access to the drug may not be achieved unless availability to the small intestinal mucosa is important and disturbed systemic circulation is taken into account. In a strict alimentary motility can reduce absorption, i.e. if sense, considerations of reduced availability apply gastric emptying is slowed by food, or intestinal whenever any drug intended for systemic effect is transit is accelerated by gut infection. The colon is given by any route other than the intravenous, but capable of absorbing drugs and many sustained- in practice the issue concerns enteral admin- release formulations probably depend on absorption istration. The extent of systemic availability is there. ordinarily calculated by relating the area under the Absorption of ionisable drugs from the buccal plasma concentration-time curve (AUC) after a mucosa is influenced by the prevailing pH which is single oral dose to that obtained after i.v. admin- 6.2-7.2. Lipid-soluble drugs are rapidly effective by istration of the same amount (by which route a this route because blood flow through the mucosa drug is 100% systemically available). Different is abundant and entry is directly into the systemic pharmaceutical formulations of the same drug can circulation, avoiding the possibility of first-pass thus be compared. Factors influencing systemic (presystemic) inactivation in the liver (see below). availability may be thought of in three main ways: The stomach does not play a major role in absorbing drugs, even those that are acidic and thus un- Pharmaceutical factors.8 The amount of drug that ionised and lipid-soluble at gastric pH, because its is released from a dose form (and so becomes surface area is much smaller than that of the small available for absorption) is referred to as its bio- intestine and gastric emptying is speedy (t/£ 30 min). availability. This is highly dependent on its pharma- ceutical formulation. With tablets, for example, particle size (surface area exposed to solution), ENTEROHEPATIC CIRCULATION diluting substances, tablet size and pressure used in This system is illustrated by the bile salts, which are the tabletting machine can affect disintegration and conserved by circulating through liver, intestine dissolution and so the bioavailability of the drug. and portal blood about eight times a day. A number Manufacturers are expected to produce a of drugs form conjugates with glucuronic acid in formulation with an unvarying bioavailability so the liver and are excreted in the bile. These that the same amount of drug is released with the glucuronides are too polar (ionised) to be reabsorbed; same speed from whatever manufactured batch or they therefore remain in the gut, are hydrolysed by brand the patient may be taking. Substantial intestinal enzymes and bacteria, releasing the parent differences in bioavailability of digoxin tablets from drug, which is then reabsorbed and reconjugated in one manufacturer occurred when only the technique the liver. Enterohepatic recycling appears to help and machinery for making the tablets were sustain the plasma concentration and thus the effect changed; also tablets containing the same amount of sulindac, pentaerythritol tetranitrate and ethinyloestradiol (in many oral contraceptives). 8 Some definitions of enteral dose-forms: Tablet: a solid dose form in which the drug is compressed or moulded with SYSTEMIC AVAILABILITY AND pharmacologically inert substances (excipients); variants include sustained-release and coated tablets. Capsule: the BIOAVAILABILITY drug is provided in a gelatin shell or container. Mixture: a liquid formulation of a drug for oral administration. When a drug is injected intravenously it enters the Suppository: a solid dose-form shaped for insertion into systemic circulation and thence gains access to the rectum (or vagina, when it may be called a pessary); it may be tissues and to receptors, i.e. 100% is available to designed to dissolve or it may melt at body temperature (in exert its therapeutic effect. If the same quantity of which case there is a storage problem in countries where the the drug is swallowed, it does not follow that the environmental temperature may exceed 37°C); the vehicle in entire amount will reach first the portal blood and which the drug is carried may be fat, glycerol with gelatin, or macrogols (polycondensation products of ethylene oxide) then the systemic blood, i.e. its availability for with gelatin. Syrup: the drug is provided in a concentrated therapeutic effect via the systemic circulation may sugar (fructose or other) solution. Linctus: a viscous liquid be less than 100%. The anticipated response to a formulation, traditional for cough. 105
7 GENERAL PHARMACOLOGY of digoxin but made by different companies, were fact that they readily enter gut mucosal cells, some shown to produce different plasma concentrations drugs appear in low concentration in the systemic and therefore different effects, i.e. there was neither circulation. The reason lies in the considerable extent bioequivalence nor therapeutic equivalence. Physicians to which such drugs are metabolised in a single tend to ignore pharmaceutical formulation as a passage through the gut wall and (principally) the factor in variable or unexpected responses because liver. This is a significant feature of the oral route, they do not understand it and feel entitled to rely and as little as 10-20% of the parent drug may reach on reputable manufacturers and official regulatory the systemic circulation unchanged. By contrast, if authorities to ensure provision of reliable formu- the drug is given intravenously, 100% becomes lations. Good pharmaceutical companies reasonably systemically available and the patient is exposed point out that, having a reputation to lose, they take to higher concentrations with greater, but more much trouble to make their preparations consistently predictable, effect. If a drug produces active reliable. This is a matter of great importance when metabolites, differences in dose may not be as great dosage must be precise (anticoagulants, antidiabetics, as those anticipated on the basis of differences in adrenal steroids). The following account by Lauder plasma concentration of the parent drug after Brunton in 1897 indicates that the phenomenon of intravenous and oral administration. Once a drug is variable bioavailability is not recent. in the systemic circulation, irrespective of which route is used, about 20% is subject to the hepatic A very unfortunate case occurred some time ago in metabolic processes in each circulation because that a doctor who had prescribed aconitine to a patient is the proportion of cardiac output that passes to the and gradually increased the dose. He thought he liver. was quite certain that he knew what he was doing. As the degree of presystemic elimination differs The druggist's supply of aconitine ran out, and he much between drugs and between individuals, the procured some new aconitine from a different phenomenon of first-pass elimination adds to maker. This turned out to be many times stronger variation in systemic plasma concentrations, and thus than the other, and the patient unfortunately particularly in initial response to the drugs that are became very ill. The doctor said, Tt cannot be the subject to this process. When a drug is taken in medicine', and to show that this was true, he drank overdose, presystemic elimination may be reduced, off a dose himself with the result that he died. So and bioavailability increased; this may explain rapid you must remember the difference in the different onset of toxicity with antipsychotic drugs, many of preparations of aconitine,9 which undergo first-pass elimination. i.e. they had different bioavailability and so lacked Drugs for which presystemic elimination is therapeutic equivalence. significant include: Biological factors. Those related to the gut include Analgesics Adrenoceptor b/ockers Others destruction of drug by gastric acid, e.g. benzyl- dextropropoxyphene labetalol clomethiazole penicillin, and impaired absorption due to intestinal morphine propranolol chlorpromazine hurry which is important for all drugs that are pentazocine metoprolol isosorbide slowly absorbed. Drugs may also bind to food pethidine oxprenolol dinitrate constituents, e.g. tetracyclines to calcium (in milk), nortriptyline and to iron, or to other drugs (e.g. acidic drugs to cholestyramine) and the resulting complex is not absorbed. In severe hepatic cirrhosis with both impaired liver cell function and well-developed channels Presystemic (first-pass) elimination. Despite the shunting blood into the systemic circulation without passing through the liver, first-pass elimination is 9 The doctor would have died of cardiac arrhythmia and/or reduced and systemic availability is increased. The cerebral depression. Aconitine is a plant alkaloid and has no result of these changes is an increased likelihood of place in medicine. exaggerated response to normal doses of drugs 106
ABSORPTION 7 having high hepatic clearance and, on occasion, For effect in the gut Advantages are that the drug is frank toxicity. placed at the site of action (neomycin, anthelminthics), Drugs that exhibit the hepatic first-pass phenom- and with nonabsorbed drugs the local concentration enon do so because of the rapidity with which they can be higher than would be safe in the blood. are metabolised. The rate at which drug is delivered Disadvantages are that drug distribution may be to the liver, i.e. blood flow, is then the main uneven, and in some diseases of the gut the whole determinant of its metabolism. Many other drugs thickness of the wall is affected (severe bacillary are completely metabolised by the liver but at a dysentery, typhoid) and effective blood concentra- slower rate and consequently loss in the first pass tions (as well as luminal concentrations) may be through the liver is unimportant. The parenteral needed. dose of these drugs does not need to be reduced to account for presystemic elimination. Such drugs include diazepam, phenytoin, theophylline, warfarin. Sublingual or buccal for systemic effect Advantages are that quick effect is obtained, e.g. ADVANTAGES AND DISADVANTAGES with glyceryl trinitrate as an aerosol spray, or as OF ENTERAL ADMINISTRATION sublingual tablets which can be chewed, giving greater surface area for solution. Spitting out the By swallowing tablet will terminate the effect. Disadvantages are the inconvenience if use has to For systemic effect Advantages are convenience be frequent, irritation of the mucous membrane and and acceptability. excessive salivation which promotes swallowing, Disadvantages are that absorption may be delayed, so losing the advantages of bypassing presystemic reduced or even enhanced after food or slow or elimination. irregular after drugs that inhibit gut motility (antimuscarinic, opioid). Differences in presystemic Rectal administration elimination are a cause of variation in drug effect between patients. Some drugs are not absorbed For systemic effect (suppositories or solutions). (gentamicin) and some drugs are destroyed in the The rectal mucosa has a rich blood and lymph gut (insulin, oxytocin, some penicillins). Tablets supply and, in general, dose requirements are either taken with too small a quantity of liquid and in the the same or slightly greater than those needed for supine position, can lodge in the oesophagus with oral use. Drugs chiefly enter the portal system, but delayed absorption10 and may even cause ulceration those that are subject to hepatic first-pass elimination (sustained-release potassium chloride and doxy- may escape this if they are absorbed from the lower cycline tablets), especially in the feeble elderly and rectum which drains directly to the systemic those with an enlarged left atrium which impinges circulation. The degree of presystemic elimination on the oesophagus.11 thus depends on distribution within the rectum and this is somewhat unpredictable. 10 A woman's failure to respond to antihypertensive Advantages are that a drug that is irritant to the medication was explained when she was observed to choke stomach can be given by suppository (aminophylline, on drinking. Investigation revealed a large pharyngeal indomethacin); the route is suitable in vomiting, pouch that was full of tablets and capsules. Her blood pressure became easy to control when the pouch was motion sickness, migraine or when a patient cannot removed. Birch D J, Dehn T C B 1993 British Medical Journal swallow, and when cooperation is lacking (sedation 306:1012. in children). 11 Ideally solid-dose forms should be taken standing up and Disadvantages are psychological in that the washed down with 150 ml (tea cup) of water; even sitting patient may be embarrassed or may like the route (higher intra-abdominal pressure) impairs passage. At least patients should be told to sit and take 3 or 4 mouthfuls of too much; rectal inflammation may occur with water (a mouthful = 30 ml) or a cupful. Some patients do not repeated use and absorption can be unreliable, even know they should take water. especially if the rectum is full of faeces. 107
7 GENERAL PHARMACOLOGY For local effect, e.g. in proctitis or colitis, an obvious extrapyramidal disorder towards the end of the use. game, presumably due to too rapid absorption of A survey in the UK showed that a substantial the drug.) proportion of patients did not remove the wrapper Advantages are that the route is reliable, suitable before inserting the suppository. for irritant drugs, and depot preparations (neuroleptics, hormonal contraceptives) can be used at monthly or longer intervals. Absorption is more rapid than ADVANTAGES AND DISADVANTAGES following subcutaneous injection (soluble prep- OF PARENTERAL ADMINISTRATION arations are absorbed within 10-30 min). (for systemic and local effect) Disadvantages are that the route is not acceptable for self-administration, it may be painful, and if any adverse effects occur to a depot formulation, it Intravenous (bolus or infusion) cannot be removed. An i.v. bolus, i.e. rapid injection, passes round the circulation being progressively diluted each time; it is delivered principally to the organs with high Subcutaneous injection blood flow (brain, liver, heart, lung, kidneys). Advantages are that the route is reliable and is Advantages are that the i.v. route gives swift, acceptable for self-administration. effective and highly predictable blood concentration Disadvantages are poor absorption in peripheral and allows rapid modification of dose, i.e. immediate circulatory failure. Repeated injections at one site cessation of administration is possible if unwanted can cause lipoatrophy, resulting in erratic absorption effects occur during administration. The route is (see Insulin). suitable for administration of drugs that are not absorbed from the gut or are too irritant (anticancer agents) to be given by other routes. By inhalation Disadvantages are the hazard if a drug is given too quickly, as plasma concentration may rise at As a gas, e.g. volatile anaesthetics. such a rate that normal mechanisms of distribution and elimination are outpaced. Some drugs will act As an aerosol, e.g. P2-adrenoceptor agonist bron- within one arm-to-tongue (brain) circulation time chodilators. Aerosols are particles dispersed in a which is 13 ± 3 seconds; with most drugs an gas, the particles being small enough to remain in injection given over 4 or 5 circulation times seems suspension for a long time instead of sedimenting sufficient to avoid excessive plasma concentrations. rapidly under the influence of gravity; the particles Local venous thrombosis is liable to occur with may be liquid (fog) or solid (smoke). prolonged infusion and with bolus doses of irritant formulations, e.g. diazepam, or microparticulate As a powder, e.g. sodium cromoglicate. Particle components of infusion fluids, especially if small size and air flow velocity are important. Most veins are used. Infection of the intravenous catheter particles above 5 micrometres in diameter impact in and the small thrombi on its tip are also a risk the upper respiratory areas; particles of about 2 during prolonged infusions. micrometres reach the terminal bronchioles; a large proportion of particles less than micrometer will be exhaled. Air flow velocity diminishes considerably Intramuscular injection as the bronchi progressively divide, promoting Blood flow is greater in the muscles of the upper drug deposition peripherally. arm than in the gluteal mass and thigh, and also Advantages are that drugs as gases can be rapidly increases with physical exercise. (Usually these taken up or eliminated, giving the close control influences are unimportant but one football-playing that has marked the use of this route in general patient who was given an intramuscular injection anaesthesia from its earliest days. Self-administration of a sustained-release phenothiazine developed an is practicable. Aerosols and powders provide 108
DISTRIBUTION 7 high local concentration for action on bronchi, liver. Glyceryl trinitrate and postmenopausal minimising systemic effects. hormone replacement therapy may be given this Disadvantages are that special apparatus is way, in the form of a sticking plaster attached to the needed (some patients find pressurised aerosols skin14 or as an ointment (glyceryl trinitrate). A nasal difficult to use to best effect) and a drug must be spray containing sumatriptan may be used to treat nonirritant if the patient is conscious. Obstructed migraine. bronchi (mucus plugs in asthma) may cause therapy to fail. Topical application Distribution If a drug is required to act throughout the body or For local effect, e.g. to skin, eye, lung, anal canal, to reach an organ inaccessible to topical admin- rectum, vagina. istration, it must be got into the blood and into Advantage is the provision of high local con- other body compartments. Most drugs distribute centration without systemic effect (usually12). widely, in part dissolved in body water, in part Disadvantage is that absorption can occur, bound to plasma proteins, in part to tissues. especially when there is tissue destruction so that Distribution is often uneven, for drugs may bind systemic effects result, e.g. adrenal steroids and selectively to plasma or tissue proteins or be neomycin to the skin, atropine to the eye. Ocular localised within particular organs. Clearly, the site administration of a (3-adrenoceptor blocker may of localisation of a drug is likely to influence its cause systemic effects (any first-pass elimination is action, e.g. whether it crosses the blood-brain bypassed) and such eye drops are contraindicated barrier to enter the brain; the extent (amount) and for patients with asthma or chronic lung disease.13 strength (tenacity) of protein or tissue binding There is extensive literature on this subject charac- (stored drug) will affect the time it spends in the terised by expressions of astonishment that serious body and thereby its duration of action. effects, even death, can occur. Drug distribution, its quantification and its clinical implications are now discussed. For systemic effect. Transdermal delivery systems (TDS) release drug through a rate-controlling membrane into the skin and so into the systemic DISTRIBUTION VOLUME circulation. Fluctuations in plasma concentration The pattern of distribution from plasma to other associated with other routes of administration are body fluids and tissues is a characteristic of each largely avoided, as is first-pass elimination in the 14 But TDS may have an unexpected outcome for, not only 12 A cautionary tale. A 70-year-old man reported left breast may the sticking plaster drop off unnoticed, it may find its enlargement and underwent mastectomy; histological way onto another person. A hypertensive father rose one examination revealed benign gynaecomastia. Ten months morning and noticed that his clonidine plaster was missing later the right breast enlarged. Tests of endocrine function from his upper arm. He could not find it and applied a new were normal but the patient himself was struck by the fact plaster. His nine-month-old child, who had been taken into that his wife had been using a vaginal cream (containing the paternal bed during the night because he needed 0.01% dienestrol) initially for atrophic vaginitis but latterly comforting, spent an irritable and hypoactive day, refused the cream had been used to facilitate sexual intercourse food but drank and passed more urine than usual. The which took place two to three times a week. On the missing clonidine patch was discovered on his back when he assumption that penile absorption of oestrogen was was being prepared for his bath. No doubt this was responsible for the disorder, exposure to the cream was accidental, but children also enjoy stick-on decoration and terminated. The gynaecomastia in the remaining breast then the possibility of poisoning from misused, discarded or new resolved (Di Raimondo C V et al 1980 New England Journal (e.g. strong opioid, used in palliative care) drug plasters of Medicine 302:1089). means that these should be kept and disposed of as carefully 13 Two drops of 0.5% timolol solution, one to each eye, can as oral formulations (Reed M T et al 1986 New England equate to 10 mg by mouth. Journal of Medicine 314: 1120). 109
7 GENERAL PHARMACOLOGY intravenous bolus dose by dividing the dose given The distribution volume of a drug is the volume in which by the concentration achieved in plasma.16 it appears to distribute (or which it would require) if the concentration throughout the body were equal to that in The result of this calculation, the distribution plasma, i.e. as if the body were a single compartment. volume, in fact only rarely corresponds with a physiological body space such as extracellular water or total body water, for it is a measure of the drug that enters the circulation and it varies between volume a drug would apparently occupy knowing drugs. Precise information on the concentration of the dose given and the plasma concentration drug attained in various tissues and fluids requires achieved and assuming the entire volume is at that biopsy samples and for understandable reasons this concentration. For this reason, it is often referred to is usually not available for humans (although as the apparent distribution volume. Indeed, for some positive emission tomography offers a prospect of drugs that bind extensively to extravascular tissues, obtaining similar information).15 What can be the apparent distribution volume, which is based sampled readily in humans is blood plasma, the on the resulting low plasma concentration, is many drug concentration in which, taking account of the times total body volume. dose, is a measure of whether a drug tends to remain in the circulation or to distribute from the Distribution volume is the volume of fluid in which the plasma into the tissues. If a drug remains mostly in drug appears to distribute with a concentration equal to the plasma, its distribution volume will be small; if that in plasma. it is present mainly in other tissues the distribution volume will be large. Such information is clinically useful. Consider The list in Table 7.2 illustrates a range of drug overdose. Removing a drug by haemodialysis apparent distribution volumes. The names of those is likely to be a beneficial exercise only if a major substances that distribute within (and have been proportion of the total body load is in the plasma, used to measure) physiological spaces are printed e.g. with salicylate which has a small distribution in italics. volume; but haemodialysis is an inappropriate treatment for overdose with dothiepin which has a Selective distribution within the body occurs large distribution volume. These, however, are because of special affinity between particular drugs generalisations and if the knowledge of distribution and particular body constituents. Many drugs bind to volume is to be of practical value it must be proteins in the plasma; phenothiazines and chloro- quantified more precisely. quine bind to melanin-containing tissues, including The principle for establishing the distribution the retina, which may explain the occurrence of volume is essentially that of using a dye to find the retinopathy. Drugs may also concentrate selectively volume of a container filled with liquid. The weight in a particular tissue because of specialised transport of dye that is added divided by the concentration of mechanisms, e.g. iodine in the thyroid. dye once mixing is complete gives the distribution volume of the dye, which is the volume of the 16 container. Similarly, the distribution volume of a Clearly a problem arises in that the plasma concentration is not constant but falls after the bolus has been injected. To get drug in the body may be determined after a single round this, use is made of the fact that the relation between the logarithm of plasma concentration and the time after a single intravenous dose is a straight line. The log 15 With positron emission tomography (PET), a positron concentration-time line extended back to zero time gives the emitting isotope, e.g. 15O, is substituted for a stable atom theoretical plasma concentration at the time the drug was without altering the chemical behaviour of the molecule. given. In effect, the assumption is made that drug distributes The radiation dose is very low but can be imaged instantaneously and uniformly through a single tomographically using photomultiplier-scintillator detectors. compartment, the distribution volume. This mechanism, PET can be used to monitor effects of drugs on metabolism in although seeming artificial, does usefully characterise drugs the brain, e.g. 'on' and 'off phases in parkinsonism. There according to the extent to which they remain in or distribute are many other applications. out from the circulation. 110
DISTRIBUTION 7 TABLE 7.2 Apparent distribution volume of some for therapeutic drug monitoring according to plasma drugs (Figures are in litres for a 70 kg person who concentration. Thyroxine and sex hormones are would displace about 70 I)17 bound in the plasma to specific globulins. Drug Distribution Drug Distribution volume volume Disease may modify protein binding of drugs to Evans blue 3 (plasma volume) atenolol 77 an extent that is clinically relevant as Table 7.3 shows. heparin 5 diazepam 140 In chronic renal failure, hypoalbuminaemia and aspirin II pethidine 280 inulin 15 (extracellular digoxin 420 retention of products of metabolism that compete water) for binding sites on protein are both responsible for gentamicin 18 nortriptyline 1000 the decrease in protein binding of drugs. Most frusemide 21 nortriptyline 1000 amoxycillin 28 dothiepin 4900 affected are acidic drugs that are highly protein antipyrine 43 (total body chloroquine 13000 bound, e.g. phenytoin, and special care is needed water) when initiating and modifying the dose of such drugs for patients with renal failure (see also Prescribing in renal disease, p. 541). PLASMA PROTEIN ANDTISSUE Chronic liver disease also leads to hypoalbumin- BINDING aemia and increase of endogenous substances such Many natural substances circulate around the body as bilirubin that may compete for binding sites on partly free in plasma water and partly bound to protein. Drugs that are normally extensively plasma proteins; these include cortisol, thyroxine, protein bound should be used with special caution, iron, copper and, in hepatic or renal failure, for increased free concentration of diazepam, byproducts of physiological intermediary metab- tolbutamide and phenytoin have been demonstrated olism. Drugs, too, circulate in the protein-bound and in patients with this condition (see also Prescribing free states, and the significance is that the free fraction in liver disease, p. 652). is pharmacologically active whereas the protein-bound The free, unbound and therefore pharmacologically component is a reservoir of drug that is inactive active percentages of some drugs are listed in because of this binding. Free and bound fractions Table 7.3 to illustrate the range and, in some cases, are in equilibrium and free drug removed from the the changes caused by disease. plasma by metabolism, dialysis or excretion is Drugs may interact competitively at plasma protein replaced by drug released from the bound fraction. binding sites as is discussed on page 131. Albumin is the main binding protein for many Tissue binding. Some drugs distribute readily to natural substances and drugs. Its complex structure regions of the body other than plasma, as a glance has a net negative charge at blood pH and a high capacity but low (weak) affinity for many basic TABLE 7.3 Examples of plasma protein binding of drugs, i.e. a lot is bound but it is readily released. drugs and effects of disease Two particular sites on the albumin molecule bind Drug % unbound (free) acidic drugs with high affinity (strongly) but these sites have low capacity. Saturation of binding sites warfarin 1 diazepam 2 (6% in liver disease) on plasma proteins in general is unlikely in the frusemide (furosemide) 2 (6% in nephrotic syndrome) doses in which most drugs are used. tolbutamide 2 Other binding proteins in the blood include clofibrate 4 ( 1 1 % in nephrotic syndrome) amitriptyline 5 lipoprotein and o^-acid glycoprotein, both of which phenytoin 9 (19% in renal disease) carry basic drugs such as quinidine, chlorpromazine triamterene 1 9 (40% in renal disease) and imipramine. Such binding may have implications trimethoprim 30 theophylline 35 (71% in liver disease) morphine 65 17 digoxin 75 (82% in renal disease) Litres per kg are commonly used, but give a less vivid amoxicillin 82 image of the implication of the term 'apparent', e.g. ethosuximide 100 chloroquine. II
7 GENERAL PHARMACOLOGY at Table 7.2 will show. These include many lipid- abolition of biological activity but various steps in soluble drugs, which may enter fat stores, e.g. most between may have the following consequences: benzodiazepines, verapamil and lignocaine. Less is 1. Conversion of a pharmacologically active to an known about other tissues, e.g. muscle, than about inactive substance: this applies to most drugs. plasma protein binding because solid tissue samples 2. Conversion of one pharmacologically active to can be obtained only by invasive biopsy, but extensive another active substance: this has the effect of binding to tissues delays elimination from the body prolonging drug action. and accounts for the long t1/2 of chloroquine and amiodarone. Displacement from tissue binding sites may be a mechanism for pharmacokinetic interaction Active drug Active metabolite (see p. 131). amitriptyline nortriptyline codeine morphine chloroquine hydroxychloroquine diazepam oxazepam Metabolism spironolactone canrenone Most drugs are treated by the body as foreign 3. Conversion of a pharmacologically inactive to an substances (xenobiotics) and become subject to its active substance, i.e. prodrugs; the effect may various mechanisms for ridding itself of chemical confer advantage or disadvantage. (The process intruders. then follows 1, above.) Metabolism is a general term for chemical transformations that occur within the body and its processes change drugs in two major ways: Inactive substance Active metabolite(s) Comment benorilate salicylic acid and possibly reduced • by reducing lipid solubility paracetamol gastric toxicity • by altering biological activity. cholecalciferol I -a-hydroxy- cholecalciferol cyclophosphamide 4-keto-cyclophosphamide REDUCING LIPID SOLUBILITY perindopril perindoprilat less risk of first dose hypotension Metabolic reactions tend to make a drug molecule levodopa dopamine levodapa, but not progressively more water-soluble and so favour its dopamine, can cross elimination in the urine. the blood-brain barrier possibly reduced gastric toxicity Drug metabolising enzymes were developed during sulindac sulindac sulphide evolution to enable the body to dispose of lipid- sulfasalazine 5-aminosalicylic acid soluble substances such as hydrocarbons, steroids terfenadine fexofenadine life-threatening and alkaloids, that are ingested with food.18 Some tachycardia if environmental chemicals may persist indefinitely in metabolism is our fat deposits, e.g. dicophane (DDT), with con- inhibited (see p. 555) sequences that are as yet unknown. zidovudine zidovudine triphosphate ALTERING BIOLOGICAL ACTIVITY THE METABOLIC PROCESSES The end result of metabolism usually is the The liver is by far the most important drug metabolising organ, although a number of tissues, 18 Fish lose lipid-soluble substances through the gills. They including the kidney, gut mucosa, lung and skin do not need such effective metabolising enzymes and they also contribute. It is useful to think of drug have not got them. metabolism in two broad phases: 12
M ETA BO LI S M 7 Phase 1 metabolism brings about a change in the Phase I oxidation of some drugs results in the drug molecule by oxidation, reduction or hydrolysis formation of epoxides which are short-lived and and often introduces a chemically active site into it. highly reactive metabolites. Epoxides are important The new metabolite may retain biological activity because they can bind irreversibly through covalent but have different pharmacokinetic properties, e.g. bonds to cell constituents; indeed, this is one of the a shorter t1/2. principal ways in which drugs are toxic to body The most important single group of reactions is tissues. Glutathione is a tripeptide that combines the oxidations, in particular those undertaken by the with epoxides, rendering them inactive, and its so-called mixed-function (microsomal) oxidases which, presence in the liver is part of an important defence as the name indicates, are capable of metabolising a machanism against hepatic damage by halothane wide variety of compounds. The most important and paracetamol. enzyme is a haem protein, cytochrome P450, which takes part in a process whereby molecular oxygen is Phase II metabolism involves union of the drug bound and incorporated into the drug molecule, so with one of several polar (water-soluble) endogenous forming a new hydroxyl group. molecules that are products of intermediary The many forms of cytochrome P450 enzymes metabolism, to form a water-soluble conjugate (called isoenzymes19) are grouped into families which is readily eliminated by the kidney or, if denoted by the letters CYP (from cytochrome P450) the molecular weight exceeds 300, in the bile. Morph- followed by numerals. The majority of enzymes ine, paracetamol and salicylates form conjugates concerned with human metabolism belong to familes with glucuronic acid (derived from glucose); oral CYP1,2 and 3. Within these families, are subdivisions contraceptive steroids form sulphates; isoniazid, denoted by a capital letter followed by a numeral. phenelzine and dapsone are acetylated. Conjugation The family CYP3A is numerically the most important, with a more polar molecule is also a mechanism being involved in the biotransformation of the by which natural substances are eliminated, e.g. majority of all drugs; indeed CYP3A4 is expressed bilirubin as glucuronide, oestrogens as sulphates. outside the liver and may be an important factor Phase II metabolism almost invariably terminates that explains poor oral availability of many drugs. bilogical activity. Over 100 drugs are known substrates for CYP2D6, > 60 for CYP2C9 and > 50 for CYP2C19.20 Another ENZYME INDUCTION isoenzyme CYP 2E1, catalyses a reaction involved in the metabolism of alcohol, paracetamol, oestradiol The mechanisms that the body evolved over and ethynyloestradiol. millions of years to metabolise foreign substances In all there may be as many as 200 separate P450 now enable it to meet the modern environmental isoenzymes and this is why we do not need to challenges of tobacco smoke, hydrocarbon pollutants, possess new enzymes for every existing or yet-to-be insecticides and drugs. At times of high exposure, synthesised drug. Each enzyme is encoded by a our enzyme systems respond by increasing in separate gene and variation in these genes leads to amount and so in activity, i.e. they are induced; differences between individuals, and sometimes when exposure falls off, enzyme production lessens. between ethnic groups, in the ability to metabolise For example, a first alcoholic drink taken after a drugs. Persons characterised by polymorphisms period of abstinence from alcohol may have quite a (see p. 122) inherit diminished ability to metabolise significant effect on behaviour but the same drink substrate drugs and if inactivation is dependent on taken at the end of two weeks' regular imbibing the particular isoenzyme, toxicity may result when may pass almost unnoticed because the individual's these drugs accumulate. liver enzyme activity is increased (induced) so that alcohol is metabolised more rapidly and has less 19 effect, i.e. tolerance has been acquired. An isoenzyme is one of a group of enzmes that catalyse the same reaction but differ in protein structure. 20 Wolf C R, Smith G, Smith R L 2000 Pharmacogenetics. Inducing substances in general share some important British Medical Journal 320: 987-990. properties: they tend to be lipid-soluble; they are 113
7 GENERAL PHARMACOLOGY substrates, though sometimes only minor ones, e.g. unrecognised cause for failure of an individual DDT, for the enzymes they induce and generally to achieve the expected response to a normal have long il/r The time for onset and offset of dose of a drug, e.g. warfarin, theophylline. induction depends on the rate of enzyme turnover • Drug toxicity may be more likely. A patient who but significant induction generally occurs within a becomes enzyme-induced by taking rifampicin is few days and it passes off over 2 or 3 weeks more likely to develop liver toxicity after following withdrawal of the inducer. paracetamol overdose by increased production It follows that the capacity of the body to of a hepatotoxic metabolite. (Such a patient will metabolise drugs can be altered by certain medicinal also present with a deceptively low plasma drugs themselves and by other substances, especially concentration of paracetamol due to accelerated when these are used long-term; clearly this phen- metabolism, see p. 287) omenon has implications for drug therapy. More than 200 substances have been shown to induce enzymes in animals but the list of proven enzyme ENZYME INHIBITION inducers in man is much more restricted. Consequences of inhibiting drug metabolism can be more profound than those of enzyme induction. Effects of enzyme inhibition by drugs also tend to be more selective than those of enzyme induction. barbecued meats griseofulvin Consequently, enzyme inhibition offers more scope barbiturates meprobamate for therapy (see Table 7.4). Brussels sprouts phenobarbital Enzyme inhibition by drugs is also the basis of a carbamazepine phenytoin number of clinically important drug interactions DDT (dicophane, primidone (see p. 133). and other rifampicin insecticides) Saint John's Wort ethanol (chronic use) sulphinpyrazone glutethimide tobacco smoke Elimination Enzyme induction is relevant to drug therapy for Drugs are eliminated from the body after being partly the following reasons: or wholly converted to water-soluble metabolites or, in some cases, without being metabolised. To • Clinically important drug interactions may avoid repetition the following account refers to result, e.g. in failure of oral contraceptives, loss drug whereas the processes deal with both drug of anticoagulant control, failure of cytotoxic and its metabolites. chemotherapy. • Disease may result. Antiepilepsy drugs increase the breakdown of dietary and endogenously TABLE 7.4 Some drugs that act by enzyme inhibition formed vitamin D, producing an inactive Drug Enzyme inhibited Treatment of metabolite — in effect a vitamin D deficiency acetazolamide carbonic anhydrase glaucoma state, which can result in osteomalacia. The allopurinol xanthine oxidase gout accompanying hypocalcaemia can increase the benserazide DOPA Parkinson's tendency to fits and a convulsion may lead to decarboxylase disease disulfiram aldehyde dehydrogenase alcoholism fracture of the demineralised bones. enalapril angiotensin converting hypertension, • Tolerance to drug therapy may result in and enzyme cardiac failure provide an explanation for suboptimal moclobemide MAO A type depression nonsteroidal cyclooxygenase pain, treatment, e.g. with an antiepilepsy drug. anti-inflammatory inflammation • Variability in response to drugs is increased. drugs Enzyme induction caused by heavy alcohol selegiline MAO B type Parkinson's disease drinking or heavy smoking may be an 114

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