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Pharmacokinetics
Pharmacokinetics
Pharmacokinetics
2 Pharmacokinetics
The biological basis of pharmacokinetics 17 ● distribution: the transfer of the drug from the general
General considerations 17
circulation into the different organs of the body
● elimination: the removal of the drug from the body,
Absorption 20
which may involve either excretion or metabolism.
Distribution 22
Each of these can be described in terms of chemical,
Elimination 25
biochemical and physiological processes and also in
The mathematical basis of mathematical terms. The mathematical description of
pharmacokinetics 31 pharmacokinetic processes determines many of the
quantitative aspects of drug prescribing:
General considerations 31
Absorption 33
● why oral and intravenous treatments may require
different doses
Distribution 35
● the interval between doses during chronic therapy
Elimination 38 ● the dosage adjustment that may be necessary in
Chronic administration 41 hepatic and renal disease
Factors affecting pharmacokinetics 43
● the calculation of dosages for the very young and
the elderly.
Pharmacogenomics, pharmacogenetics and drug
responses 43
Pharmacology
D D D
D D D
Pore or open Diffusion Carrier Closed
ion-channel through protein ion-channel
lipid bi-layer (carrier-
mediated
process)
Fig. 2.2
18 The passage of drugs (D) across membrane bilayers.
Ch02.qxd 3/12/05 10:58 AM Page 19
Pharmacokinetics
2
Pinocytosis. This can be regarded as a form of carrier- elimination). The ease with which a drug can enter and
mediated entry into the cell cytoplasm. Pinocytosis is cross a lipid bilayer is determined by the lipid solubility
normally concerned with the uptake of macromolecules; of its un-ionised form. Drugs that are fixed in their
however, successful attempts have been made to utilise ionised form at all pH values, such as the quaternary
it for targeted drug uptake by incorporating the drug amines, cross membranes extremely slowly or not at all;
into a lipid vesicle or liposome (e.g. amphotericin and they have limited effects on the brain (because of lack of
doxorubicin – Ch. 51). entry) and are given by injection (because of lack of
A number of reversible and irreversible processes absorption from the intestine).
can influence the total concentration of drug present on The extent of ionisation of a drug depends on the
each side of the membrane (Fig. 2.3). Ionisation is a strength of the ionisable group and the pH of the
fundamental property of most drugs and will occur solution. The extent of ionisation is given by the acid
whenever the drug is in solution. The majority of drugs dissociation constant Ka.
are either weak acids, such as aspirin, or weak bases,
such as propranolol. The presence of an ionisable Conjugate acid Conjugate base + H+
group(s) is essential for the mechanism of action of most
Ka = [conjugate base] [H+] (2.1)
drugs, because ionic forces represent a key part of
ligand–receptor interactions. Drug receptors are formed [conjugate acid]
by the three-dimensional arrangement of a protein
(Ch. 1), and drug binding requires both lipid- and The term conjugate acid refers to a form of the drug able
water-soluble sites within the drug molecule; the latter to release a proton, such as an un-ionised acidic drug
are usually produced by an ionisable functional group. (Drug–COOH) or an ionised basic drug (Drug–NH3+).
The overall polarity of the drug and its extent of The conjugate base is the corresponding equilibrium
ionisation determine the extent of distribution (for form of the drug that has lost the proton, such as an
example, entry into the brain), accumulation in adipose ionised acidic drug (Drug–COO−) or an un-ionised basic
tissue, and mechanism and route of elimination from drug (Drug–NH2).
the body. Ionisation is a fundamental property and occurs For acidic drugs, the value of Ka is normally low (e.g.
when drugs containing acidic or basic groups dissolve 10−5) and therefore it is easier to compare compounds
in an aqueous body fluid. using the negative logarithm of the Ka, which is called
the pKa (e.g. 5).
[Acidic drug] [Acidic drug]− + H+ For acidic functional groups, a strong acid will have
a high tendency to dissociate to give H+; this results in a
[Basic drug] + H+ [Basic drug – H]+ high value for Ka (e.g. 10−1 or 10−2) and numerically a low
pKa (e.g. 1 or 2). Thus, strongly acidic groups (such as
In general terms, the ionised form of the molecule can be Drug–SO3H) have a pKa of 1–2, while weakly acidic
regarded as the water-soluble form and the un-ionised groups (such as a phenolic–OH) have a pKa of 9–10. In
form as the lipid-soluble form. Drugs with ionisable contrast, for basic functional groups, the stronger the
groups exist as an equilibrium between charged and base, the greater will be its ability to retain the H+ as a
uncharged forms. The extent of ionisation can affect conjugate acid – resulting in a low Ka and a high pKa.
both the pharmacodynamics (for example, the affinity Thus, strongly basic groups (such as R–NH2 where R is
for the receptor) and the pharmacokinetics (for example, an alkyl group) have a pKa of 10–11, while weakly basic
the extent of uptake by adipose tissue and the route of groups (such as R3N) have a pKa of 2–3.
Ionisation D D D Ionisation
Fig. 2.3
Passive diffusion and the factors that affect the concentrations of drug freely available in solution (as an equilibrium between un-ionised
and ionised forms). 19
Ch02.qxd 3/12/05 10:58 AM Page 20
The pH of body fluids is controlled by the buffering Urine (pH 6) Membrane Plasma (pH 7.4)
capacity of the ionic groups present in endogenous
molecules such as phosphate ions and proteins. When For an acidic
drug (DH)
the fluids on each side of a membrane (see Fig. 2.3) have
the same pH values, there will be equal concentrations – –
D DH DH DH D
of both the diffusible, un-ionised form and the polar
ionised form of the drug on each side of the membrane
at equilibrium. When the fluids on each side of a mem- Overall
brane are at different pH values, the concentration of
ionised drug in equilibrium with the un-ionised will be
determined by the pH of the solution and the pKa of the
drug. This results in pH-dependent differences in drug For a basic drug (D)
concentration on each side of a membrane (pH parti-
tioning). The pH differences between plasma (pH 7.4) + +
and stomach contents (pH 1–2) and urine (pH 5–7) can DH D D D DH
influence drug absorption and drug elimination.
Drugs are 50% ionised when the pH of the solution Overall
equals the pKa of the drug. Acidic drugs are most
ionised when the pH of the solution exceeds the pKa, Fig. 2.5
Partitioning of acidic and basic drugs across a pH gradient.
whereas basic drugs are most ionised when the pH is
lower than the pKa (Fig. 2.4). The practical importance is
that the total concentration of drug will be higher on the the stomach empties and the drug can be absorbed from
side of the membrane where it is most ionised (Fig. 2.5), the lumen of the duodenum (pH about 8).
which has implications for drug absorption from the
stomach and the renal elimination of some drugs. In
drug overdose, increasing the pH of the urine can
enhance the renal elimination of acidic drugs, such as
aspirin, by retaining the ionised drug in the urine (see
Absorption
below), whereas a decrease in urine pH can be useful for
basic drugs, such as dexamfetamine. It is important to Absorption is the process of transfer of the drug from
realise that changing urine pH in the wrong direction the site of administration into the general or systemic
for the type of drug taken in overdose will make matters circulation.
worse and could kill the person!
The low pH of the stomach contents (usually pH 1–2)
means that most acidic drugs are present largely in their
Absorption from the gut
un-ionised (proton-associated) form and pH partition- The easiest and most convenient route of administration
ing allows the drug to pass into plasma (pH 7.4) where of medicines is orally by tablets, capsules or syrups;
it is more ionised. In contrast, basic drugs are highly however, this route presents the greatest number of
ionised in the stomach and absorption is negligible until barriers for the drug prior to reaching the systemic
circulation. A number of factors can affect the rate and
extent to which a drug can pass from the gut lumen into
Low pH the general circulation.
–
Acid Acid-H
Drug structure
High pH
Drug structure is a major determinant of absorption,
(e.g. – COO–) (e.g. – COOH)
distribution and elimination. Drugs need to be lipid
soluble to be absorbed from the gut. Therefore, highly
High pH polar acids and bases tend to be absorbed only slowly
and incompletely, with much of the dose not absorbed
Base-H+ Base
but voided in the faeces. High polarity may be useful for
Low pH delivery of the drug to the lower bowel (see Ch. 34). The
(e.g. – NH3+) (e.g. – NH2) structure of some drugs can make them unstable either
Ionised Un-ionised at the low pH of the stomach, for example penicillin G,
water- lipid- or in the presence of digestive enzymes, for example
soluble form soluble form insulin. Such compounds have to be given by injection,
Fig. 2.4 but other routes of delivery may be possible (e.g.
20 The effect of pH on drug ionisation. inhalation for insulin).
Ch02.qxd 3/12/05 10:58 AM Page 21
Pharmacokinetics
2
Drugs that are weak acids or bases may undergo pH to split amide, ester and glycosidic bonds. Intestinal
partitioning between the gut lumen and mucosal cells. proteases prevent the oral administration of peptides,
Acidic drugs will be least ionised in the stomach lumen, which are the usual products derived from molecular
and most absorption would be expected at this site. biological approaches to drug development. In addition,
However, the potential for absorption in the stomach is the lower bowel contains large numbers of aerobic and
decreased by its low surface area and the presence of a anaerobic bacteria, which are capable of performing a
zone at neutral pH on the immediate surface of the range of metabolic reactions, especially hydrolysis and
gastric mucosal cells (the mucosal bicarbonate layer). In reduction.
consequence, even weak acids, such as aspirin, tend to Intestinal wall. The cells of the wall are rich in
be absorbed mainly from the small intestine. Basic drugs enzymes such as monoamine oxidase (MAO), L-aromatic
are highly ionised in the stomach; as a result, absorption amino acid decarboxylase, CYP3A4 (see below) and the
does not occur until the drug has passed from the enzymes responsible for the phase 2 conjugation reac-
stomach to the small intestine. tions (see below). In addition, the luminal membrane of
the intestinal cells contains the efflux transporter PGP,
Formulation which transfers some drugs that have entered the cell
Drugs cannot be absorbed until the administered tablet/ back into the intestinal lumen. Drug molecules that enter
capsule disintegrates and the drug is dissolved in the the enterocyte may undergo three possible fates – i.e.
gastrointestinal contents to form a molecular solution. diffuse into the hepatic portal circulation, undergo
Most tablets disintegrate and dissolve rapidly and com- metabolism within the cell, or be transported back into
pletely and all of the dose is rapidly available for absorp- the gut lumen by PGP. There are overlapping substrate
tion. However, some formulations are produced that specificities of CYP3A4 and PGP, and for common sub-
disintegrate slowly so that the rate at which the drug is strates the combined actions can prevent the majority of
absorbed is limited by the rate of release and dissolution an oral dose reaching the portal circulation.
of drug from the formulation, rather than by the transfer Liver. Blood from the intestine is delivered directly
of the dissolved drug across the gut wall. This is the to the liver, which is the major site of drug metabolism
basis for modified-release formulations (e.g. slow-release) in the body (see metabolism, below).
in which the drug either is incorporated into a complex Lung. Cells of the lung have high affinity for many
matrix from which it diffuses, or is administered in a basic drugs and are the main site of metabolism for
crystallised form that dissolves only slowly. Dissolution many local hormones via MAO or peptidase activity.
of a tablet in the stomach can be prevented by coating it If there is extensive metabolism at one or more of
in an acid-insoluble layer, producing an enteric-coated these sites, only a fraction of the administered oral dose
formulation, for example omeprazole and aspirin. This may reach the general circulation. This process is known
allows delivery of intact drug to the duodenum. as first-pass metabolism because it occurs at the first
passage through these organs. The liver is generally the
Gastric emptying most important site of first-pass metabolism. Hepatic
The rate of gastric emptying determines the rate at which metabolism can be avoided by administration of the
a drug is delivered to the small intestine, which is the drug to a region of the gut from which the blood does
major site of absorption. A delay between dose admin- not drain into the hepatic portal vein, for example the
istration and the detection of the drug in the circulation buccal cavity and rectum. A good example of avoiding
is seen frequently after oral dosing, and is usually caused hepatic first-pass metabolism is the buccal administra-
by delayed gastric emptying. The co-administration of tion of glyceryl trinitrate (Ch. 5).
drugs that slow gastric emptying, for example antimus-
carinics, can alter the rate of drug absorption.
Food has a complex effect on drug absorption since
Absorption from other routes
it reduces the rate of gastric emptying and delays Percutaneous (transcutaneous) administration
absorption, but it can also alter the total amount of drug The human epidermis (especially the stratum corneum)
absorbed. represents an effective permeability barrier to water
loss and to the transfer of water-soluble compounds.
First-pass metabolism Although lipid-soluble drugs are able to cross this
Metabolism of drugs (see below) can occur prior barrier, the rate and extent of entry are very limited. In
to and during absorption, and this can limit the consequence, this route is only really effective for use
amount of parent compound reaching the general with potent non-irritant drugs, such as glyceryl
circulation. Drugs taken orally have to pass four trinitrate, or to produce a local effect. The slow and
major metabolic barriers before they reach the general continued absorption from dermal administration (e.g.
circulation. via adhesive patches) can be used to produce low, but
Intestinal lumen. This contains digestive enzymes relatively constant, blood concentrations, e.g. the use of
secreted by the mucosal cells and pancreas that are able nicotine patches. 21
Ch02.qxd 3/12/05 10:58 AM Page 22
Intradermal and subcutaneous injection only 5–10% of the dose may be absorbed from the air-
Intradermal or subcutaneous injection avoids the barrier ways, even when the administration technique generates
presented by the stratum corneum, and entry into the mostly small particles (i.e. 5 µm or less). Particles less
general circulation is limited largely by the blood flow than 1 µm in diameter are not deposited in the airways
to the site of injection. However, these sites only allow and are exhaled.
the administration of small volumes of drug and tend to
be used for local effects, such as local anaesthesia, or Minor routes
to limit the rate of drug absorption, for example insulin. Although drugs may be applied to all body surfaces and
Slow uptake from the site of injection, as seen with some orifices, this is usually to produce a local and not a
insulin preparations, can result in an increased duration systemic effect. However, absorption from the site of
of action. administration may be important in limiting the
duration of action and in producing unwanted systemic
Intramuscular injection actions.
The rate of absorption from an intramuscular injection
depends on two variables: the local blood flow and the
water solubility of the drug, both of which enhance the
rate of removal from the injection site. Absorption of
drugs from the injection site can be prolonged inten-
Distribution
tionally either by incorporation of the drug into a lipid
vehicle or by formation of a sparingly soluble salt, such Distribution is the process by which the drug is
as procaine benzylpenicillin, thereby creating a depot transferred reversibly from the general circulation into
formulation. the tissues as the concentrations in blood increase, and
from tissues into blood when the blood concentrations
Intranasal administration decrease. For most drugs this occurs by simple diffusion
The nasal mucosa provides a good surface area for of the un-ionised form across cell membranes until
absorption, combined with lower levels of proteases equilibrium is reached (Fig. 2.3). At equilibrium, any
and drug-metabolising enzymes compared with the process that removes the drug from one side of the
gastrointestinal tract. In consequence, intranasal adminis- membrane results in movement of drug across the
tration is used for the administration of some potent membrane to re-establish the equilibrium (Fig. 2.3).
peptides, such as desmopressin (Ch. 43), as well as for After an intravenous injection, there is a high initial
drugs that are designed to produce local effects, such as plasma concentration, and the drug may rapidly enter
nasal decongestants. and equilibrate with well-perfused tissues such as the
brain, liver and lungs (Table 2.1), giving relatively high
Inhalation concentrations in these tissues. However, the drug will
Although the lungs possess the characteristics of a good continue to enter poorly perfused tissues, and this will
site for drug absorption (a large surface area and exten- lower the plasma concentration. The high concentrations
sive blood flow), inhalation is rarely used to produce in the rapidly perfused tissues then decrease in parallel
systemic effects. The principal reason for this is the with the decreasing plasma concentrations, which
difficulty of delivering non-volatile drugs to the alveoli. results in a transfer of drug back from those tissues into
Therefore, drug administration by inhalation is largely the plasma (Fig. 2.6). In most cases, the uptake into well-
restricted to: perfused tissues is so rapid that these tissues may be
assumed to equilibrate instantaneously with plasma and
● volatile compounds, such as general anaesthetics
represent part of the ‘central’ compartment (see below).
● locally acting drugs, such as bronchodilators used in
Redistribution from well-perfused to poorly perfused
asthma
tissues is of clinical importance for terminating the
● potent agents, such as ergotamine for migraine, since
action of some drugs that are given as a rapid intra-
this route avoids the gastric stasis that is a common
venous injection or bolus. For example, thiopental
feature of a migraine attack.
produces rapid anaesthesia after intravenous dosage,
The last two groups present technical problems for but this is short lived because continued uptake into
administration because the drugs are not volatile and muscle lowers the concentrations in the blood and in the
have to be given either as aerosols containing the drug brain (section A to B in Fig. 2.6; see also Fig.17.2).
or as fine particles of the solid drug. Particles greater The processes of elimination (such as metabolism
than 10 µm in diameter settle out in the upper airways, and excretion) are of major importance and are discussed
which are poor sites for absorption, and the drug then in detail below. Elimination processes lower the
passes back up the airways via ciliary motion and is concentration of the drug within the cells of the organ
eventually swallowed. The optimum particle size for that eliminates the drug; this results in a transfer from
22 airways deposition is 2–5 µm. It has been estimated that plasma into the drug-eliminating cells in order to
Ch02.qxd 3/12/05 10:58 AM Page 23
Pharmacokinetics
2
Table 2.1
decrease in drug concentrations in both plasma and
Relative organ perfusion rates in humansa tissues.
A
drug decreases, for example through metabolism, then
this will affect all the equilibria shown in Figure 2.3.
B
Plasma
Concentration
Clofibrate Chlorpromazine
Time Digitoxin Propranolol
Furosemide Quinidine
Fig. 2.6
Ibuprofen Tricyclic antidepressants
A simplified scheme for the redistribution of drugs between
tissues. The initial decrease in plasma concentrations results from Indometacin Lidocaine
uptake into well-perfused tissues, which essentially reaches equilibrium Phenytoin
at point A. Between points A and B, the drug continues to enter poorly Salicylates
perfused tissues, which results in a decrease in the concentrations in Sulphonamides
both plasma and well-perfused tissues. At point B, all tissues are in Thiazides
equilibrium. N.B. The scheme has been simplified by representing the
Tolbutamide
phases as discrete linear steps and also by the omission of any removal
process. The presence of a removal process would produce a parallel Warfarin
decrease in all tissues from point B (shown as ----). 23
Ch02.qxd 3/12/05 10:58 AM Page 24
Drug will dissociate from intracellular protein-binding soluble drugs into the brain is much slower than into
sites, and some will transfer across the membrane from other well-perfused tissues, and this has given rise to
plasma until the intracellular equilibria are re-established. the concept of a blood–brain barrier. The functional basis
As a result, the extracellular (plasma) concentration of of the barrier (Fig. 2.7) is reduced capillary permeability
unbound drug will decrease, and drug will dissociate owing to:
from plasma protein-binding sites. The ratio of the total
● tight junctions between adjacent endothelial cells
amount of drug in the extracellular and intracellular
(the capillaries are composed of an endothelial cell
compartments is determined by the relative affinity of
layer without smooth muscle)
the intra- and extracellular binding proteins.
● a decrease in the size and number of pores in the
Competition for protein binding can occur between
endothelial cell membranes
different drugs (drug interaction; see Ch. 56), and also
● the presence of a surrounding layer of astrocytes.
between drugs and natural, endogenous ligands.
Administration of a highly protein-bound drug (such as
aspirin) to an individual who is already receiving main-
tenance therapy with a drug that binds reversibly to
plasma proteins (such as warfarin; see Ch. 11) will result
in displacement of the initial drug from its binding sites; Non-tight
this increases the unbound concentration and therefore junction
the biological activity. In practice, such protein-binding
interactions are frequently of limited duration because Foot process of astrocyte
the extra free drug is removed by metabolism or excretion.
Tight junctions between
An important interaction involving the displacement endothelial cells
of an endogenous compound occurs in infants given
drugs such as sulphonamides: drugs that compete for
the same albumin binding sites as endogenous bilirubin
can displace the bilirubin and cause a potentially danger-
ous increase in its plasma concentration. Endothelial cell
Pharmacokinetics
2
Therefore, only lipid-soluble compounds can readily molecule (which would be reabsorbed from urine in the
enter the brain. Water-soluble endogenous compounds kidney tubule) into a water-soluble species (which is
needed for normal brain functioning, such as carbohy- capable of rapid elimination in the urine). The drug
drates and amino acids, enter the brain via specific itself is eliminated as soon as metabolism converts it
transport processes. Some drugs, for example levodopa, into a different chemical structure. However, the elimi-
may enter the brain using these transport processes, and nation of the unwanted carbon skeleton of the drug may
in such cases the rate of transport of the drug will be involve a complex series of biotransformation reactions
influenced by the concentrations of competitive endoge- (see below).
nous substrates. Metabolism of the parent drug produces a new
There is limited drug-metabolising ability in the chemical entity, which may show different pharmaco-
brain and drugs leave by diffusion back into plasma, by logical properties:
active transport processes in the choroid plexus, or by
● complete loss of biological activity, which is the
elimination in the cerebrospinal fluid. Transporters,
usual result of drug metabolism; this can increase
such as PGP, in the endothelial cells are an important
polarity (especially phase 2 metabolism – see below)
part of the blood–brain barrier, and serve to return drug
and prevent receptor binding
molecules that have entered the cell back into the circu-
● decrease in activity, when the metabolite retains
lation, thereby preventing their entry into the brain and
some activity
reducing any effects in the central nervous system.
● increase in activity, when the metabolite is more
Organic acid transporters are important in removing
potent than the parent drug
polar neurotransmitter metabolites from the brain.
● change in activity, when the metabolite shows
different pharmacological properties which can be
Fetus
less active or more toxic
Lipid-soluble drugs can readily cross the placenta and
enter the fetus. The placental blood flow is low com- The various steps of drug metabolism can be divided
pared with that in the liver, lung and spleen (Table 2.1); into two phases (Fig. 2.8). Although many compounds
consequently, the fetal concentrations equilibrate slowly undergo both phases of metabolism, it is possible for a
with the maternal circulation. Highly polar and large chemical to undergo only a phase 1 or a phase 2
molecules (such as heparin; see Ch. 11) do not readily reaction. Phase 1 metabolism (oxidation, reduction and
cross the placenta. The fetal liver has only low levels of hydrolysis) is usually described as preconjugation,
drug-metabolising enzymes. It is maternal elimination because it produces a molecule that is a suitable sub-
processes that predominantly control fetal concentra- strate for a phase 2 or conjugation reaction. The enzymes
tions of drug; lowering of maternal concentrations allows involved in these reactions have low substrate speci-
drug to diffuse back across the placenta from fetal to ficities and can metabolise a vast range of drug sub-
maternal circulation. strates (as well as most environmental pollutants). In
After delivery, the baby may show effects from drugs this section, drug metabolism is discussed in terms of
given to the mother close to delivery (such as pethidine the functional groups that may be found in different
for pain control; see Ch. 19): such effects may be pro- drugs, rather than individual specific compounds. (In
longed because the infant now has to rely on his or her the following tables, R refers to an aliphatic or aromatic
own immature elimination processes (Ch. 54). group and Ar refers specifically to an aromatic group.)
OH O – SO3–
Elimination Phase
1
Phase
2
Percentage
Elimination is the removal of drug from the body and
ionised Benzene Phenol Phenylsulfate
may involve metabolism, in which the drug molecule is at pH 7.4 0% 0.3% 99.9%+
transformed into a different molecule, and/or excretion,
Fig. 2.8
in which the drug molecule is expelled in the body’s The two phases of drug metabolism.
liquid, solid or gaseous ‘waste’.
Phase 1
Metabolism Oxidation is by far the most important of the phase 1
Lipid solubility is an essential property of most drugs, reactions and can occur at carbon, nitrogen or sulphur
since it allows the compound to cross lipid barriers and atoms (Table 2.3). In most cases, an oxygen atom is
hence to be given via the oral route. Metabolism is retained in the metabolite, although some reactions,
essential for the elimination of lipid-soluble chemicals such as dealkylation, result in loss of the oxygen atom in
from the body, because it converts a lipid-soluble a small fragment of the original molecule. 25
Ch02.qxd 3/12/05 10:58 AM Page 26
Table 2.3
2.10), followed by reduction (via a specific cytochrome
Oxidation reactions P450 reductase) and then binding of molecular oxygen.
Further reduction is followed by molecular rearrange-
Oxidation at carbon atoms ment, with release of the reaction products and regen-
Aromatic ArH → ArOH eration of ferric cytochrome P450.
Alkyl RCH3 → RCH2OH → RCHO → RCOOH
Oxidations at nitrogen and sulphur atoms are fre-
Dealkylation ROCH3 → ROH + HCHO
quently performed by a second enzyme of the endoplas-
RNHCH3 → RNH2 + HCHO
Deamination RCH2NH2 → RCHO + NH3
mic reticulum, the flavin-containing mono-oxygenase,
RCH(CH3)NH2 → RCO(CH3) + NH which also requires molecular oxygen and NADPH. A
number of other enzymes, such as alcohol dehydro-
Oxidation at nitrogen atoms genase, aldehyde oxidase and MAO, may be involved in
H OH the oxidation of specific functional groups.
Reduction can occur at unsaturated carbon atoms and
Secondary amines R′ – N – R → R′ – N – R at nitrogen and sulphur centres (Table 2.5); such reactions
Tertiary amines R3N→R3N→O are less common than oxidation. Reduction reactions
can be performed both by the body tissues and also by
Oxidation at sulphur atoms
the intestinal microflora. The tissue enzymes include
O cytochrome P450 and cytochrome P450 reductase.
↑ Hydrolysis and hydration reactions (Table 2.6) involve
Thioethers R–S–R → R–S–R
addition of water to the drug molecule. In hydrolysis,
R, aliphatic or aromatic group; Ar, aromatic group. the drug molecule is split by the addition of water. A
number of enzymes present in many tissues are able to
hydrolyse ester and amide bonds in drugs. The intes-
Oxidation reactions are catalysed by a diverse group tinal flora are also important for the hydrolysis of esters
of enzymes, of which the cytochrome P450 system is the and amides and of drug conjugates eliminated in the bile
most important. Cytochrome P450 is a superfamily of (see below). In hydration reactions, the water molecule
membrane-bound enzymes (Table 2.4) which are present is retained in the drug metabolite. The hydration of the
in the smooth endoplasmic reticulum of cells (Fig. 2.9). epoxide ring to produce a dihydrodiol (Table 2.6) is
The liver is the major site of drug oxidation. The amounts performed by a microsomal enzyme, epoxide hydrolase.
of cytochrome P450 in extrahepatic tissues are low This is an important reaction in the metabolism and
compared with those in liver. toxicity of a number of aromatic compounds, for exam-
Cytochrome P450 is a haemoprotein that can bind ple the drug carbamazepine (Ch. 23).
both the drug and molecular oxygen (Fig. 2.10). It
catalyses the transfer of one oxygen atom to the sub- Phase 2
strate while the other oxygen atom is reduced to water: Phase 2 or conjugation reactions involve the synthesis
of a covalent bond between the drug, or its phase 1
RH + O2 + NADPH + H+ → ROH + H2O + NADP+ metabolite, and a normal body constituent (endogenous
substrate). Energy to synthesise the bond is supplied
The reaction involves initial binding of the drug sub- by activation of either the endogenous substrate or
strate to the ferric (Fe3+) form of cytochrome P450 (Fig. the drug. The types of phase 2 reactions are listed in
Table 2.4
The cytochrome P450 superfamily
Pharmacokinetics
2
50 T
Cytoc
hrom P4 DG
P450 e UP
e
D tiv
Active Acite MGA
site s
D M
Phospholipid
bilayer
D in M M D = Drug
cytosol D in M = Metabolite
M cytosol MGA = Metabolite–glucuronide conjugate
MS
MS = Metabolite–sulphate conjugate
MS
Fig. 2.9
Drug metabolism in the smooth endoplasmic reticulum. The lipid-soluble drug (D) partitions into the lipid bilayer of the endoplasmic reticulum.
The cytochrome P450 oxidises the drug to a metabolite (M) that is more water soluble and diffuses out of the lipid layer. The metabolite may
undergo a phase 2 (conjugation) reaction with UDP-glucuronyl transferase (UDPGT) in the endoplasmic reticulum or sulphate in the cytosol, to give
a glucuronide conjugate (MGA) or a sulphate conjugate (MS), respectively.
Table 2.7, which shows the functional group necessary synthesis is uridine-diphosphate glucuronic acid
in the drug molecule and the activated species for the (UDPGA), which is synthesised from UDP-glucose. The
reaction. In most cases, the reaction involves an acti- enzymes that transfer the glucuronic acid moiety to the
vated endogenous substrate. The products of conjuga- drug (UDP-glucuronyl transferases) occur in the endo-
tion reactions are usually highly water soluble and with- plasmic reticulum close to the cytochrome P450 system,
out biological activity. the products of which frequently undergo glucuronida-
The activated endogenous substrate for glucuronide tion (Fig. 2.9). Glucuronide synthesis occurs in many
ROH
RH
H2O Fe3+
+
2H
Fe3+ RH
Fe3+ RH
e– From NADPH-
O2– cytochrome P450
2
Fe2+ RH reductase
From reduced e–
cytochrome b5 O2
or cytochrome Fe3+ RH
P450 reductase Fe2+ RH
_
O2
O2
Fig. 2.10
The oxidation of substrate (RH) by cytochrome P450. Fe3+, the active site of cytochrome P450 in its ferric state; RH, drug substrate; ROH, oxidised
metabolite. Cytochrome b5 is present in the endoplasmic reticulum and can transfer an electron to cytochrome P450 as part of its redox reactions. 27
Ch02.qxd 3/12/05 10:58 AM Page 28
R, aliphatic or aromatic group; Ar, aromatic group. R, R′, different aliphatic/aromatic groups.
tissues, especially the gut wall and liver, where it may primarily involved in the inactivation of neurotrans-
contribute significantly to the first-pass metabolism of mitters such as noradrenaline or of local hormones such
substrates such as simple phenols. as histamine.
In contrast, sulphate conjugation is performed by a The conjugation of drug carboxylic acid groups with
cytosolic enzyme, which utilises high-energy sulphate amino acids is unusual because the drug is converted
(3′-phosphoadenosine-5′-phosphosulphate or PAPS) as to a high-energy form (a CoA derivative) prior to the
the endogenous substrate. The capacity for sulphate formation of the conjugate bond. The enzymes involved
conjugation is limited by the availability of PAPS, rather in the formation of the drug CoA derivatives are
than the transferase enzyme. Sulphate conjugation is involved in the metabolism of intermediate-chain-
highly dose-dependent, and saturation of sulphate con- length fatty acids. Conjugation of the drug CoA
jugation contributes to the metabolic events involved in derivative with an amino acid is catalysed by trans-
the liver toxicity seen in paracetamol (acetaminophen in ferase enzymes.
the USA) overdose (see Ch. 53). Conjugation with the tripeptide glutathione (L-α-
The reactions of acetylation and methylation fre- glutamyl-L-cysteinylglycine) is important in drug
quently decrease, rather than increase, polarity, because toxicity. This reaction is catalysed by a family of trans-
they block an ionisable functional group. These reac- ferase enzymes and the product has a covalent bond
tions mask potentially active functional groups such between the drug, or its metabolite, and the thiol group
as amino and catechol moieties, and the enzymes are in the cysteine (Fig. 2.11). The substrates are often
Table 2.7
Major conjugation reactions
Pharmacokinetics
2
Unstable drug or reactive drugs or activated metabolites, which are
Glutathione
reactive metabolite inherently unstable (see Ch. 53), and the reaction can
GLU also occur non-enzymatically. Glutathione conjuga-
RX HS CYS tion is a detoxication reaction in which glutathione
acts as a scavenging agent to protect the cellfrom
GLY toxic damage. The initial glutathione conjugate under-
goes a series of subsequent metabolic reactions,
Glutathione transferase which illustrates the complexity of drug metabolism
or spontaneous reaction
(Fig. 2.11).
GLU A good example of a drug that undergoes a com-
R S CYS plex array of biotransformation reactions is diazepam
(Fig. 2.12). Cytochrome P450-mediated oxidation and
GLY
removal of the N-methyl group (see Table 2.3) produces
Hydrolysis N-desmethyldiazepam, which retains biological activity
at GABAA receptors. Both diazepam and N-desmethyl-
R S Cysteine diazepam undergo ring oxidation, giving temazepam
and oxazepam, respectively, which are also used as
N-acetylation Lyase anxiolytics and sedatives (see Ch. 20). Oxazepam
and temazepam contain an aliphatic hydroxyl group,
Excretory R SH which is conjugated with glucuronic acid, giving an
product inactive, water-soluble excretory product. In addition,
temazepam can undergo N-demethylation to give
Further metabolism
oxazepam.
Fig. 2.11
The formation and further metabolism of glutathione conjugates.
CH3 CH3
O O
N N
Cytochrome P450 UDPGT Water-soluble
OH glucuronide
Ring oxidation conjugate
Cl N Cl N
Diazepam Temazepam
H H
O O
N N
Cytochrome P450 UDPGT Water-soluble
OH glucuronide
Ring oxidation conjugate
Cl N Cl N
Desmethyldiazepam Oxazepam
(nordiazepam)
Fig. 2.12
The pathways of metabolism of diazepam in humans. This figure illustrates that a single drug may generate a number of metabolites, which may
possess similar pharmacological properties. UDP-glucuronyl transferase (UDPGT) is the enzyme that transfers glucuronic acid from UDPGA to the
alicyclic OH group. 29
Ch02.qxd 3/12/05 10:58 AM Page 30
Pharmacokinetics
2
soluble. The urine is concentrated on its passage down General circulation
the renal tubule and the tubule-to-plasma concentration
gradient increases, so that only the most polar and least
diffusible molecules will remain in the urine. Because of Drug
extensive reabsorption, lipid-soluble drugs are not
eliminated via the urine, and are retained in the Liver
circulation until they are metabolised to water-soluble
Drug Conjugate
products (see above), which are efficiently removed
from the body. The pH of urine is usually less than that
of plasma; consequently, pH partitioning, between urine
(pH 5–6) and plasma (pH 7.4), may either increase or
decrease the tendency of the compound to be
Bile
reabsorbed (see above).
Tubular secretion. The renal tubule has secretory
transporters on both the basolateral and apical mem-
branes for compounds that are acidic (organic anion
Small
transporters – OATs 1–4) or basic (organic cation trans- Drug
intestine
porters – OCTs 1–3). In addition, there are multidrug
resistance-associated proteins (MRPs), which were Conjugate
originally identified in a cell line resistant to anticancer
drugs but have since been found as important trans- Conjugate
porters in various tissues. Drugs and their metabolites
(especially the glucuronic acid and sulphate conjugates) Colon/rectum
Conjugate
may undergo an active carrier-mediated elimination, Drug
primarily by OATs but also by MRPs. Because secretion Drug
Bacterial hydrolysis
lowers the plasma concentration of unbound drug by an
active process, there will be a rapid dissociation of any Fig. 2.13
Enterohepatic circulation of drugs.
drug–protein complex; as a result, even highly protein-
bound drugs may be cleared almost completely from
the blood in a single passage through the kidney.
Excretion via the faeces have a greater lipid solubility than the glucuronic acid
Uptake into hepatocytes and subsequent elimination in conjugate and will be absorbed from the gut lumen and
bile is the principal route of elimination of larger enter the hepatic portal vein (Fig. 2.13).
molecules (those with a molecular weight greater than
about 500 Da). Conjugation with glucuronic acid
increases the molecular weight of the substrate by
almost 200 Da, and therefore bile can be an important The mathematical basis
route for the elimination of glucuronide conjugates.
Once the drug, or its conjugate, has entered the
of pharmacokinetics
intestinal lumen via the bile, it passes down the gut and
eventually may be eliminated in the faeces. However, The use of mathematics to describe the fate of a drug in
some drugs may be reabsorbed from the lumen of the the body can be complex and rather daunting for under-
gut and re-enter the hepatic portal vein. As a result, the graduates. Nevertheless, a basic understanding is essen-
drug is recycled between the liver, bile, gut lumen and tial for an appreciation of many aspects of drug handling
hepatic portal vein. This is described as an enterohepatic and for the rational prescribing of drugs. The following
circulation (Fig. 2.13); it can maintain the drug account gives the mathematics for the absorption,
concentrations in the general circulation, because some distribution and elimination of a single dose of a drug,
of the reabsorbed drug will escape hepatic extraction before brief consideration of chronic (repeat-dose)
and pass through the sinusoids from the hepatic portal administration and the factors that can affect pharma-
vein into the hepatic vein. Highly polar glucuronide cokinetic processes.
conjugates of drugs, or their oxidised metabolites, that
are excreted into the bile undergo little reabsorption in
the upper intestine, but the bacterial flora of the lower
intestine can hydrolyse the conjugate back to the
General considerations
original drug, or its oxidised metabolite, and glucuronic Two different but complementary approaches can be
acid. The original drug, or its primary metabolite, will used to describe pharmacokinetics. 31
Ch02.qxd 3/12/05 10:58 AM Page 32
● Compartmental model analysis. Plasma The units of k (the reaction rate constant) will be an
concentration–time curves are described by an amount per unit time (e.g. mg min−1). A graph of concen-
equation containing one or more exponential tration against time will produce a straight line with a
functions. This approach gives a precise mathematical slope of −k (Fig. 2.14a).
description of the concentration–time curve and can
be used to predict the concentration of drug at any First-order reactions
time after a dose. However, it is difficult to relate the In first-order reactions, the change in concentration at
mathematical values to the physiological disposition any time (dC/dt) is proportional to the concentration
of the compound. present at that time:
● Model-independent analysis. This approach may be
related more closely to the physiological processes dC
= –kC (2.3)
governing the disposition of the chemical. It is more dt
useful in predicting the influence of variables such
as disease, age and the administration of other The units of the rate constant, k, are time−1 (e.g. h−1), and
compounds on the concentrations of the drug. k may be regarded as the proportional change per unit
of time. The rate of change will be high at high con-
Some undergraduate texts provide details of compart- centrations but low at low concentrations (Fig. 2.14b),
mental analysis, but the model-independent methods and a graph of concentration against time will produce
are of greater potential value to medical undergraduates an exponential decrease. Such a curve can be described
and are the basis of the following account. by an exponential equation:
The three basic processes that need to be described
mathematically are absorption, distribution and elimi- C = C0e−kt (2.4)
nation. For each process, it is important to know the rate
or speed with which the drug is processed and the extent where C is the concentration at time t and C0 is the initial
of the process, i.e. the amount or proportion of drug that concentration (when time = 0). This equation may be
undergoes that process. written more simply by taking natural logarithms:
For nearly all physiological and metabolic processes,
the rate of reaction is proportional to the amount of sub- lnC = lnC0 − kt (2.5)
strate (drug) available: this is described as a first-order
reaction. Diffusion down a concentration gradient and and a graph of lnC against time will produce a straight
glomerular filtration are examples of first-order reac- line with a slope of −k and an intercept of lnC0
tions. Protein-mediated reactions, such as metabolism (Fig. 2.14c).
and active transport, are also first-order at low concen- The units of k (which are time−1, e.g. h−1) are difficult
trations because if the concentration of the substate is to use practically, and therefore the rate of a first-order
doubled, then the formation of product is doubled. reaction is usually described in terms of its half-life
However, as the substrate concentration increases, the (which has units of time). The half-life is the time taken
enzyme or transporter can become saturated with sub- for a concentration to decrease to one-half. The half-life
strate and the rate of reaction cannot increase in is independent of concentration (Fig. 2.15) and is a
response to a further increase in concentration. The characteristic for that particular first-order process and
process then occurs at a fixed maximum rate that is that particular drug. The decrease in plasma concentra-
independent of substrate concentration, and the reac- tion after an intravenous bolus dose is shown in Figure
tion is described as a zero-order reaction; examples are the 2.15, which has been plotted such that the concentration
metabolism of ethanol (Ch. 54) and phenytoin (Ch. 23). is halved every hour.
When the substrate concentration has decreased suffi- The relationship between the half-life and the rate
ciently for protein sites to become available again, then constant is derived by substituting C0 = 2 and C = 1 into
the change in concentration will proceed at a rate the above equation, when the time interval t will be one
proportional to the concentration available – in other half-life (t 1⁄2).
words, the reaction will revert to first-order.
ln1 = ln2 − kt 1⁄2 (2.6)
Zero-order reactions
0 = 0.693 − kt 1⁄2
If a drug is being processed (absorbed, distributed or
eliminated) according to zero-order kinetics, then the 0.693
t1/2 =
change in concentration with time (dC/dt) is a fixed k
amount per time – independent of concentration:
A half-life can be calculated for any first-order process
dC (e.g. for absorption, distribution or elimination); in
= –k (2.2)
32 dt practice, the ‘half-life’ reported for a drug is the half-life
Ch02.qxd 3/12/05 10:58 AM Page 33
Pharmacokinetics
2
Zero order First order
Slope = – k InC0
(units = mass time–1)
Slope = – k
(units = time–1)
InC
C
(a) Time C
(b) Time (c) Time
Fig. 2.14
Zero- and first-order kinetics. C, concentration; k, rate constant.
100 5
80 4
In (concentration)
Slope = –k
60 3
C
40 2
20 1
0 0
0 1 2 3 4 0 1 2 3 4
Time (h) Time (h)
Fig. 2.15
The elimination half-life of a drug in plasma. Here the concentration (C) decreases by 50% every hour, i.e. the half-life is 1 h.
for the elimination rate (i.e. the slowest, terminal phase absorption, distribution and elimination (Fig. 2.16a).
of the plasma concentration–time curve; see below). However, for most drugs, the distribution phase is not
seen after oral dosage (Fig 2.16b). The rate of absorption
after oral administration is determined by the rate at
which the drug is able to pass from the gut lumen into
the systemic circulation. The rate of absorption influences
Absorption the shape of the plasma concentration–time curve after
an oral dose, as shown in Figure 2.17. For lipid-soluble
The mathematics of absorption apply to all ‘non- drugs, there is an initial steep increase, from which the
intravenous’ routes – for example, oral, inhalation, per- absorption rate constant (ka) can be calculated, and a
cutaneous, etc. – and are illustrated by absorption from slower decrease, from which the elimination rate con-
the gut lumen. stant (k) can be calculated. In Figure 2.17a, the absorp-
tion is essentially complete by point B since the sub-
sequent data are fitted by a single exponential rate
Rate of absorption constant (the elimination rate) (see below).
For some drugs, it is possible to see three distinct phases A number of factors can affect this apparently simple
in the plasma concentration–time curve that reflect pattern. 33
Ch02.qxd 3/12/05 10:58 AM Page 34
(a) Rate of absorption > rate of distribution (b) Rate of absorption < rate of distribution
concentration
concentration
Plasma drug
Plasma drug
Time after dosage Time after dosage
Absorption phase Absorption phase
Distribution phase Distribution phase
Elimination phase Elimination phase
Fig. 2.16
Plasma concentration–time profiles after oral administration. The processes of distribution and elimination start as soon as some of the drug has
entered the general circulation. A clear distribution phase is seen if the rate of absorption is extremely rapid, so that absorption is complete before
distribution is finished (Fig. 2.16a). For most drugs, the rate of absorption is slow compared with the rate of distribution, and distribution occurs as
rapidly as the drug is absorbed; therefore, distribution is complete when absorption is complete, and a clear distribution phase is not seen (Fig 2.16b).
● Gastric emptying. Basic drugs undergo negligible drug that reaches the general circulation but will not
absorption from the stomach (see above). In affect the rate of absorption (which is usually
consequence, there can be a delay of up to an hour determined by lipid solubility). Therefore, the curve
between drug administration and the detection of is parallel but at lower concentrations (Fig. 2.17d).
drug in the general circulation (Fig. 2.17b). ● Modified-release formulation. If a drug is eliminated
● Food. The pattern of absorption can be affected by rapidly, the plasma concentrations will show rapid
changes in gastric emptying (Fig. 2.17b) and food can fluctuations during regular oral dosing, and patients
alter the absorption rate, i.e. value of ka (Fig. 2.17c). may have to take the drug at very frequent intervals.
● Decomposition or first-pass metabolism prior to or This can be avoided by giving a tablet that releases
during absorption. This will reduce the amount of drug at a slow and predictable rate over many
(b) (c)
–k
–k
In C
In C
(a)
B
Slope = –k
In C
C A
Time Time
Slope determined
by ka (d) (e)
Slope = –kdiss
A Time
In C
In C
–k –k
Time Time
Fig. 2.17
Plasma concentration–time curves following oral administration. (a) General profile (A, start of absorption; B, end of absorption; B–C, elimination
[rate = k]) (this ‘normal’ profile is repeated as a green line in panels b–e). (b) Influence of gastric emptying: there is a delay between t = 0 and A. (c)
Influence of food: slower absorption results in a reduction in the absorption rate constant (ka) derived from A–B. (d) Decrease in bioavailability
(owing to incomplete dissolution of formulation, decomposition, increased first-pass metabolism). (e) Slow-release formulation: the rate at which the
34 drug can be eliminated is limited by the rate at which the formulation disintegrates (kdiss).
Ch02.qxd 3/12/05 10:58 AM Page 35
Pharmacokinetics
2
hours: a modified-release formulation. The profile is An alternative method to calculate F is to measure
affected by continuing absorption from the intestine, the total urinary excretion of the parent drug (Aex) fol-
and the terminal slope of the concentration–time lowing oral and intravenous doses (even in situations
curve is then determined by the dissolution rate of where the urine is a minor route of elimination), and:
the oral formulation, not by the elimination of the
drug from the circulation (Fig. 2.17e). Aexoral
F= (2.9)
Aexiv
A A
Slope = –k
D
InC
InC
B
Slope = – β
B
C
Time Time
Model Model
k12
Dose V k Dose V1 V2
k21
k10
One-compartment Two-compartment
Fig. 2.18
Plasma concentration–time curves for the distribution of drugs into one- and two-compartment models. The terms k, α, β, k10, k12, k21, are rate
constants; α and β are composite rate constants which define the distribution and elimination rates. The terms α and β relate to distribution (k12 or
k21) and elimination (k10) processes and are determined by k10, k12, and k21. V are volumes of distribution, and X and Y are constants. (Note: the
equation for a two-compartment system is usually written as C = Ae−αt + Be−βt, where A and B are constants equivalent to X and Y; X and Y were used
to avoid confusion with points A and B on the graph.)
Instantaneous and slow distributions are described For some drugs, the natural logarithm of the plasma
by different mathematical models: the former is des- concentration–time curve shows three distinct phases;
cribed as a one-compartment model (Fig. 2.18a), in which such curves require three exponential rates and repre-
all tissues are in equilibrium instantaneously; the latter sent a three-compartment model. Although two- or three-
is described as a two-compartment model (Fig. 2.18b), in compartment models may be necessary to give a
which the drug initially enters and reaches instanta- mathematical description of the data, they are of limited
neous equilibrium with one compartment (blood and practical value.
possibly well-perfused tissues) prior to equilibrating
more slowly with a second compartment (possibly
poorly perfused tissues; refer back to Fig. 2.6). This is
Extent of distribution
shown schematically in Figure 2.19. The extent of distribution of a drug from plasma into
The rate of distribution is dependent on two main tissues is of clinical importance because it determines
variables: the relationship between the measurable plasma con-
centration and the total amount of drug in the body
● for water-soluble drugs, the rate of distribution (body burden). In consequence, the extent of distribu-
depends on the rate of passage across membranes, tion determines the amount of a drug that has to be
i.e. the diffusion characteristics of the drug administered in order to produce a particular plasma
● for lipid-soluble drugs, the rate of distribution concentration (see below).
depends on the rate of delivery (the blood flow) to The extent of distribution of a drug from blood or
those tissues, such as adipose, that accumulate the plasma into tissues can be determined in animals by
36 drug. measuring concentrations in both blood and all the
Ch02.qxd 3/12/05 10:58 AM Page 37
Pharmacokinetics
2
Total amount (dose) 50 000 µg
V= = = 50 000 ml = 50 l
Dose Plasma concentration 1 µg ml–1
Dose
tissues of the body. However, in humans, only the con- V= (2.11)
Concentration at point D
centration in blood or plasma can be measured, and
therefore the extent of distribution has to be estimated Alternative equations for the calculation of V are pre-
from the amount remaining in blood, or more usually sented below.
plasma, after completion of distribution. V is not a physiological volume but simply a reflec-
The parameter that describes the extent of distribu- tion of the amount of drug remaining in the blood or
tion is the apparent volume of distribution (V), where: plasma after distribution and provides no information
on where the drug has been taken up. Thus, a high value
Total amount of drug in the body for V could result from either reversible accumulation
V= (2.10)
Plasma concentration in adipose tissue (owing to dissolution in fat) or
reversible accumulation in liver and lung (owing to high
The apparent volume of distribution is a characteristic intracellular protein binding). The actual tissue distri-
property of the drug that, like half-life, bioavailability bution can be determined only by measurement of
and clearance, is independent of dose. In the simple tissue concentrations.
example shown by Figure 2.18a, if a dose of 50 mg of a The value of V is usually calculated using the total
particular drug is injected, this will mix instantaneously concentration in plasma – that is, free (unbound) drug
into the apparent volume of distribution V. If the initial plus protein-bound drug. A low value for V can result if
plasma concentration is 1 µg ml−1 (equivalent to point A a drug is highly bound to plasma proteins but not to
on Fig. 2.18a), then the apparent volume of distribution tissue proteins; if the drug shows an even higher affinity
will be given by: for tissue (lipid or protein; see Fig. 2.3), then it will have 37
Ch02.qxd 3/12/05 10:58 AM Page 38
a high value for V. The term V reflects the relative affinity Table 2.9
of plasma and tissues for a drug, and there is no simple The apparent volume of distribution (V) and plasma-protein
relationship between plasma-protein binding and V binding of selected drugs
(Table 2.9).
If the tissues have a very high affinity for the drug, Drug V Binding (%)
( kg–1)
the value of V will be extremely high and may greatly
exceed the bodyweight. Chloroquine is a good example Warfarin and furosemide 0.1 99
of such a drug (Table 2.9) and the value illustrates clearly Aspirin 0.2 49
that V should be regarded as a mathematical ratio (not Gentamicin 0.3 <10
as an indication of physiological distribution to an Propranolol 3.9 93
actual volume of plasma!). Nortriptyline 18.5 95
The term V represents the volume of plasma that has Chloroquine 185.7 61
to be cleared of drug by the organs of elimination, such
as the liver and kidneys, which extract the drug from the Note: V is given in /kg body weight; therefore, for
chloroquine, the total volume of distribution will be 13 000
plasma and remove it from the body by metabolism or per 70 kg patient.
excretion. It is independent of dose or concentration.
Because V is constant, a twofold increase in plasma con-
centration will be accompanied by a twofold increase in
the total amount of drug in the body (Equation 2.10).
Although apparent volume of distribution may seem a
Rate of elimination
rather abstract (and possibly even irrelevant) parameter, The rate of elimination is usually indicated by the ter-
it is important for two reasons. Firstly, it is the parameter minal half-life – that is, the half-life for the final (slowest)
that relates the total body drug load present at any time rate (k in Fig. 2.18a; β in Fig. 2.18b). The elimination half-
to the plasma concentration. Secondly, together with lives of drugs range from a few minutes to many days
clearance, it determines the overall elimination rate con- (and, in rare cases, weeks). Precise knowledge about the
stant (k) and therefore the half-life. The half-life deter- half-life of every drug is not necessary and, therefore, in
mines the duration of action of a single dose, the time this book we have used the descriptive terms given in
interval between doses on repeated dosage and the Table 2.10 to indicate the approximate half-life and the
potential for accumulation (see below). influence this would have on clinical use of the drug.
The rate at which a drug can be eliminated from the
body, and therefore the half-life, is determined by two
independent, biologically-determined variables: the
activity of the mechanisms metabolising/excreting
Elimination the drug and the extent of movement of drug from the
blood into tissues.
Elimination can also be described in terms of both rate The activity of the metabolising enzymes or excre-
and extent. The rate at which the drug is eliminated is tory mechanisms. The organs of elimination (usually
important because it usually determines the duration of liver and kidneys) remove drug that is brought to them
response, the time interval between doses, and the time via the blood. Providing that first-order kinetics apply
to reach equilibrium during repeated dosing. The extent (in other words, the process is not saturated), a constant
of elimination is eventually 100%. The route of proportion of the drug carried in the blood will be
elimination is important because it can determine the removed on each passage through the organ of elimi-
effects of renal/liver disease, age and drug interactions. nation, independent of the concentration in the blood. In
Table 2.10
Half-life descriptions used in this book
Pharmacokinetics
2
effect, this is equivalent to a constant proportion of the equilibration with tissues, the blood or plasma concen-
blood flow to the organ being cleared of drug. The more tration is very low, then V is very high. The low plasma
active the process (e.g. hepatic metabolism), the greater concentration will result in a low rate of elimination from
will be the proportion of the blood flow cleared of drug the body; in other words, the rate at which the drug can
on one passage through the organ. For example, if 10% be eliminated will be limited by the extent of tissue
of the drug carried to the liver by the plasma (at a flow distribution. Therefore, the elimination rate constant (k)
rate of 800 ml min–1) is cleared, by uptake and metabo- is inversely proportional to the apparent volume of
lism, this is equivalent to a clearance of 10% of the distribution.
plasma flow (80 ml min–1); if 20% of the drug is cleared,
this gives a clearance of 160 ml min–1. The proportion of 1 (2.13)
k∝
the blood flow cleared of drug will have units of volume V
per time (e.g. ml min–1). The plasma clearance (CL) of the
drug is the sum of all clearance processes (metabolism + Plasma clearance
renal + bile + exhalation + etc.) and is the volume of The overall rate of elimination is dependent on the two
plasma cleared of drug per unit time; it is the best indi- variables, the volume of plasma cleared per minute (CL)
cation of the overall activity of the elimination processes. and the total apparent volume of plasma that has to be
cleared (V):
Rate of elimination from the body
CL = (2.12) CL
Plasma concentration k= (2.14)
V
µg min –1
For example = ml min–1 or
µg ml–1
0.693V 0.693
t1⁄2 = since t1⁄2 =
The plasma clearance is a characteristic value for a CL k
particular drug (see Table 2.11), is a constant for first-
order (non-saturated) reactions, and is independent of This is illustrated in Figure 2.20 and Table 2.11. The
dose or concentration. Because clearance is constant elimination rate constant (or half-life) is the best indi-
(Equation 2.12), a twofold increase in plasma concen- cation of changes in drug concentration with time, and
tration will be accompanied by a twofold increase in the for many drugs this will relate to changes in therapeutic
rate of elimination. The greater the value of plasma activity following a single dose. Clearance is the best
clearance, the greater will be the rate at which the drug measurement of the ability of the organs of elimination
will be removed from the body, i.e. the elimination rate to remove the drug and determines the average plasma
constant (k) is proportional to plasma clearance. concentrations (and therefore therapeutic activity) at
Reversible passage of drug from the blood into steady state (see below). Clearance is usually determined
tissues. The organs of elimination can only act on drug using the area under the concentration–time curve
that is delivered to them via the blood supply. If, after (AUC).
Table 2.11
Pharmacokinetic parameters of selected drugs
Warfarin 3 8 37
Digitoxin 4 38 161
Diazepam 27 77 43
Valproic acid 76 27 5.6
Digoxin 130 640 39
Ampicillin 270 20 1.3
Amlodipine 333 1470 36
Nifedipine 500 80 1.8
Lidocaine 640 77 1.8
Propranolol 840 270 3.9
Imipramine 1050 1600 18
Note: The drugs are arranged in order of increasing plasma clearance. A long half-life may result from a low clearance (e.g.
digitoxin), a high apparent volume of distribution (e.g. amlodipine) or both.
39
Ch02.qxd 3/12/05 10:58 AM Page 40
Dose
Volume (ml) CL = = kV
AUC
Clearance Dose Dose
(ml min–1) V= or (2.16)
AUC × k AUC × β
Pharmacokinetics
2
Biliary clearance of a drug can be measured using the
above approach, but in practice is seldom done, because
D B C
of the difficulty of collecting bile samples. Css
Extent of elimination
Slope = –k
The extent of elimination is of limited value because
InC
eventually all the drug will be removed from the body.
Measurement of total elimination in urine, faeces and
expired air as parent drug and metabolites can give
useful insights into the extent of absorption, metabolism,
and renal and biliary elimination.
A Time
Chronic administration Fig. 2.21 Constant intravenous infusion (between points A and C).
Steady state is reached at point B and the steady-state concentration
(Css; given by D) can be used to calculate clearance: CL = rate of
infusion/Css (see text). Clearance can also be calculated from the area
Long-term or chronic drug therapy is designed to main- under the total curve (AUC) and the total dose infused between A and
tain a constant concentration of the drug in blood, with C. The slope on cessation of infusion is the terminal elimination phase
an equilibrium (steady state) established between blood (k or β). The distribution phase is not usually detected because
distribution is occurring throughout the period A to C. The apparent
and all tissues of the body, including the site of action. volume of distribution can be calculated as: V = Dose/(AUC × k). The
In practice, a constant concentration can only be achieved increase to steady state is determined by the elimination rate constant
by an intravenous infusion that has continued long and it takes approximately four to five half-lives to reach steady state.
enough to reach steady state (Fig. 2.21).
Table 2.12
Plasma concentrations following a change in dosagea
Drug concentration in plasma (ng ml–1) after a change in dose rate (mg h–1) Percentage
change A-E
A B C D E
(1 to 0) (1 to 0.5) (1 to 2) (0 to 1) (0 to 2)
a
Theoretical changes in plasma concentrations of a drug that has been given by continuous intravenous infusion.
Notes:
The steady-state concentrations (initial and infinity) are directly proportional to the infusion rate.
The percentage changes (from initial conditions to infinity) are identical and independent of the rate of infusion.
After four or five half-lives, the change in concentration represents about 95% of the overall change to infinity (the new steady state).
Clearance = rate of infusion/Css = 1 000 000 ng h–1/100 ng ml–1 = 167 ml min.–1
41
Ch02.qxd 3/12/05 10:58 AM Page 42
Rate of infusion
Css = (2.19) Loading dose
CL
A therapeutic problem may arise when a rapid effect is
This relationship for an intravenous infusion can be required for a drug that has a long or very long half-life;
used to calculate plasma clearance: for example, the steady-state conditions will not be
reached until 2–4 days if the half-life is 12–24 h, or over
Rate of infusion 4 or 5 weeks if the half-life is 1 week. Increasing the dose
CL = (2.20)
Css rate (for example, column E compared with column D in
Table 2.12) does not reduce the time to reach steady
Clearance and volume of distribution can also be state. A higher dose rate will reduce the time taken to
calculated using the AUC between zero and infinity and reach any particular concentration, but plasma concen-
the terminal slope after cessation of the infusion (see trations will continue to increase to give a higher steady-
Fig. 2.21). state level (after the same time interval of about four or
five half-lives).
Any delay between the initiation of treatment and
Oral administration the attainment of steady state may be avoided by the
Most chronic administration is via the oral route, and administration of a loading dose. A loading dose is a high
the rate and extent of absorption need to be considered.
Also, oral therapy is by intermittent doses and therefore
there will be a series of peaks and troughs between
doses (Fig. 2.22).
The rate of absorption will influence the interdose
profile, since very rapid absorption will exaggerate Css
fluctuations, while slow absorption will dampen down
the peak.
The extent of absorption, or bioavailability (F), will
InC
D×F
(2.21)
t
Time
where D is the administered dose, F is bioavailability,
and t is the interval between doses. At steady state, the Fig. 2.22
rate of input is balanced by the rate of elimination, that is: Chronic oral therapy (——) compared with intravenous (- - - -)
infusion at the same dosage rate. The oral dose shows very rapid
absorption and distribution followed by a more slow elimination
D×F
= CL × Css (2.22) phase within each dose interval. Cessation of therapy after any dose
42 t would produce the line shown in blue.
Ch02.qxd 3/12/05 10:58 AM Page 43
Pharmacokinetics
2
initial or first dose that, as the name implies, is designed state) concentrations in the slowly equilibrating tissues
to ‘load up’ the body. In principle, this is done by giving (see Fig. 2.6). The excessive concentrations in rapidly
a first dose that is equivalent to the total steady-state equilibrating tissues may give rise to toxicity. This can
body load which would be produced by the intended be minimised by giving the loading dose in fractions,
chronic dosage regimen. This will avoid the slow build- which would allow distribution of one fraction before
up to steady state, and the steady-state body load can the next was given. The fractional loading doses should
then be maintained by giving the dosage regimen that be given within the period of the normal dose interval.
would eventually have resulted in the same steady-state
concentration. The amount of drug equivalent to the
steady-state body load is the target Css multiplied by V
(see Equation 2.10). Factors affecting
Loading dose = Css × V (2.24) pharmacokinetics
In cases where Css or V are not known, the loading dose
A number of factors can affect the physiological
can be calculated based on the proposed maintenance
processes of absorption, distribution and elimination.
regimen by replacing Css with Equation 2.24 and V by
Aspects such as pregnancy, age, and diseases of the
CL/k (Equation 2.14):
organs of elimination are discussed in Chapter 56.
Clinically important variability arises from differences
D×F CL
Loading dose = × in bioavailability, V and CL:
t × CL k
● drug interactions: see Chapter 56, and the induction
D×F and inhibition of P450 discussed above
=
t×k ● age: see Chapter 56
● diseases, especially of the liver and kidneys: see
D × F × 1.44 × t 1⁄ 2 Chapter 56
= (2.25)
t ● environmental factors, for example alcohol and
smoking
It is clear from this last equation that the magnitude of ● genetics: this is becoming an increasingly important
any loading dose compared with the maintenance dose area and is discussed in detail below in relation to
is proportional to the half-life. pharmacokinetics and in Chapter 4 in relation to
Good examples of drugs that may require a loading receptors.
dose are the cardiac glycosides digoxin and digitoxin,
which are compared in Table 2.13. The values given in
Table 2.13 are to illustrate the concept of a loading dose:
the doses used clinically should take into account body- Pharmacogenomics,
weight, age, and the presence of severe renal or liver
impairment. pharmacogenetics and drug
Loading doses may need to be given in two or three
fractions over a period of about 24–36 h. The reason is
responses
that during tissue distribution of the loading dose, there
are higher (non-steady-state) concentrations in the blood There are person-to-person variations for any biological
and rapidly equilibrating tissues, and lower (non-steady- property, including the responses to drug administra-
Table 2-13
Pharmacokinetics and dosage for digoxin and digitoxin
Digoxin Digitoxin
tion. The nature of the response is usually similar in all expression of the gene in response to the regulatory
individuals, because they share the same underlying transcription factors that control that gene product;
biology, but the magnitude of the response to the same the gene product will be the same as the normal or
dose of a drug can differ markedly within a group of ‘wild’ type of gene product
individuals. For many responses, this variation is ● in the coding region of the gene, which will result in
reflected in a single Gaussian distribution (Fig. 2.23a), a gene product with an altered amino acid sequence
and such variability is an inherent part of the need to that may have higher activity (although this is
individualise dosage for the person. The presence of a unlikely), similar activity, lower activity or no
polymorphism (Fig. 2.23b) can give rise to much wider activity at all.
person-to-person variation in response, such that some
In addition, there can be other inactive SNPs because
individuals may show no response, while others show
they are in non-coding or silent regions of the genome,
toxicity at the same dose. The genetic origins of many
or because the base change does not alter the amino acid
polymorphisms is of increasing importance both in rela-
encoded (although this can result in altered expresson –
tion to drug development (see Ch. 3) and also because it
see PGP below). In consequence, a major challenge for
allows the possibility in the future for genetic screening
the future is not in identifying SNPs and the presence of
to be used to individualise drug and dosage selection.
genotypic differences, but rather in defining the func-
Pharmacogenetics relates to how genetic differences
tional consequences of the genetic difference and the
between individuals affect the fate of a drug or the
magnitude of phenotypic differences. Future research
response to a drug. Pharmacogenetic research has been
will also focus on the importance of different combina-
undertaken for more than four decades, largely in rela-
tions of genetic variants (haplotypes) rather than on
tion to in vivo variability, and has often used classic
single gene differences.
genetic techniques such as studies in twins and patterns
The rapid advances in molecular biology have
of inheritance.
allowed analysis of person-to-person differences in the
Pharmacogenomics relates to genome-wide approaches
sequences of the genes involved in drug metabolism
that define the presence of single-nucleotide polymor-
and drug transport (pharmacokinetics) and receptors
phisms (SNPs) in the genes which affect the activity of
(pharmacodynamics). The earliest studies on pharma-
the gene product. Molecular biological techniques have
cogenetics were performed in relation to enzymes
allowed recognition of more than 1.4 million SNPs in
involved in drug metabolism. N-Acetyltransferase was
the human genome. SNPs can be:
one of the first drug metabolism pathways to be shown
● in the upstream regulatory sequence of a coding to have a genetic influence on both plasma concen-
gene, which can result in increased or decreased trations of a drug (isoniazid) and the therapeutic
Number of subjects
Response Response
Fig. 2.23
Inter-individual variation in response to a single dose. The graphs show the numbers of individuals in a population showing a particular level of
response to a single dose of a drug against the magnitude of the response. In Figure 2.23a, most individuals show the average response and the
overall shape is a normal distribution. In a normal monomorphic distribution (Fig. 2.23a), the magnitude of inter-individual variability is indicated by
the coefficient of variation (the dotted line in Figure 2.23a is for a response showing wider inter-individual variation). Both the coefficient of variation
44 and the magnitude of the difference between phenotypes affect the variation in a polymorphic distribution (Fig. 2.23b).
Ch02.qxd 3/12/05 10:58 AM Page 45
Pharmacokinetics
2
response. Individuals with low enzyme activity, so- pharmacogenetics remained of largely academic interest
called ‘slow acetylators’, had higher blood concen- until the late 1970s, when it was found that CYP2D6 –
trations of isoniazid and a better response but a greater one of the isoforms of cytochrome P450, the major drug-
risk of toxicity than did ‘fast acetylators’. Because metabolising enzyme – showed a functionally impor-
N-acetylation is a minor pathway of drug metabolism, tant genetic polymorphism that could affect a wide
Table 2-14
Pharmacogenetic differences in drug-metabolising enzymes
Phase I reactions
Plasma 1 in 3000 Suxamethonium Prolonged paralysis
pseudocholinesterase (succinylcholine)
Phase II reactions
N-Acetyltransferase 50% (10–20% Isoniazid, hydralazine, Enhanced drug response in slow
in Asians) procainamide acetylators
Glucuronyl- 10% (1–4% in Asians) Irinotecan (bilirubin) Enhanced effect (Gilbert’s syndrome)
transferase 1A1
Thiopurine S-methyl 0.3% Mercaptopurine, azathioprine Increased risk of toxicity (because the
transferase doses normally used are close to toxic)
Transporters
PGP A number of SNPs Digoxin, anti-cancer drugs, Possibly higher drug levels with some
have been identified, dihydropyridines SNPs, but lower drug levels due to
the incidences of increased activity with other SNPs
which vary with
ethnic origins
a
Incidence for Caucasians
PGP, P-glycoprotein; SNP, single-nucleotide polymorphism
45
Ch02.qxd 3/12/05 10:58 AM Page 46
variety of different drugs. It is now known that the basic population may be different; for example, subjects from
genotypic difference relates to the coding of an inactive the Indian subcontinent show a two- to threefold lower
enzyme in those without appreciable CYP2D6 activity – systemic clearance of nifedipine (a CYP3A substrate)
‘poor metabolisers’ – but that 75 different alleles have compared with Caucasians, and this probably has a
been described and also there are variations in the genetic basis in the control of enzyme expression.
number of copies of the coding region, with normal There is an increasing interest in pharmacogenetics
‘extensive metabolisers’ having one copy of the normal of transporter proteins. Although in its infancy, com-
gene, although individuals with up to 13 copies have pared with pharmacogenetics of drug metabolism, the
been been identified. Cytochrome P450 was one of the available data indicate that there are functionally impor-
earliest enzyme systems to be a focus of research on tant polymorphisms in some adenosine triphosphate
human genomics. (ATP)-binding transporter proteins. A number of SNPs
Knowledge of the precise nature of the differences have been identified in the MDR1 gene, which codes for
(SNPs) for genetic polymorphisms is beyond the scope PGP, although the consequences of this for drug trans-
of an undergraduate text, and is not necessary to under- port and for the aetiology of diseases are not clear. There
stand or appreciate either the current position or pos- are splice variants for the OAT transporters in the
sible future developments in the area of pharmaco- kidneys, but, again, the incidence and consequences of
genomics. There is a well-established database on these for humans have not been defined.
genetic differences in many of the major pathways of Information on genetic polymorphisms and genetic
foreign compound metabolism (Table 2.14), and the variants of the enzymes and transporters involved in
functional consequences are outlined. Ethnic origins can drug metabolism and biodisposition can be found on
affect the proportion of the population showing a the OMIM (Online Mendelian Inheritance in Man;
genetic deficiency or polymorphism (see Table 2.14). In John Hopkins University) database (http://www.ncbi.
addition, the extent of metabolism in the general nlm.nih.gov/entrez/dispomim.cgi?id=235200).
46
Ch02.qxd 3/12/05 10:58 AM Page 47
Pharmacokinetics
2
k. Drugs are always taken with meals in order to
reduce unwanted effects.
Self-assessment
2. Figure 2.24 shows the changes in plasma levels of
1. The following statements describe drug
Self-assessment questions
two drugs, A and B, given as 10-mg doses by oral
pharmacokinetics. Are they true or false?
and intravenous routes. From the plasma
a. The plasma clearance of a drug usually decreases concentration–time curves, compare the two drugs
with increase in the dose prescribed. for the following properties (do not perform
b. First-pass metabolism may limit the detailed calculations):
bioavailability of orally administered drugs.
a. Absorption from the gut.
c. Drugs that show high first-pass metabolism in
b. Oral bioavailability.
the liver also have a high systemic clearance.
c. Distribution to tissues.
d. The half-life of many drugs is longer in infants
d. Elimination half-life.
than in children or adults.
e. Extent of accumulation during daily
e. A decrease in renal function may affect both
administration of each drug.
systemic clearance and oral bioavailability.
f. Benzathine benzylpenicillin has a prolonged
3. The pharmacokinetics of three drugs, A, B
half-life because the renal extraction of penicillin
and C, were studied in the blood and urine
is reduced.
of a healthy adult male volunteer (70 kg) following
g. Nifedipine is eliminated more rapidly in cigarette
both oral and intravenous administration of
smokers.
20-mg doses (Table 2.15). From the data given,
h. Chronic treatment with phenobarbital can
compare:
increase the systemic clearance and oral
bioavailability of co-administered drugs. a. The extent of absorption (bioavailability, F) (you
i. A loading dose is not necessary for drugs that cannot calculate the rate of absorption from these
have short half-lives. data).
j. An obese person is likely to show an increased b. The apparent volume of distribution (V) (you
volume of distribution and decreased clearance cannot calculate the rate of distribution from
of prescribed drugs. these data).
1000 A 1000 B
Plasma concentration (ng ml–1)
100 100
Oral
Intravenous
Intravenous
10 10
Oral
1 1
10 20 30 10 20 30
Time (h) Time (h)
Fig. 2.24
Plasma concentration–time curves for two drugs. 47
Ch02.qxd 3/12/05 10:58 AM Page 48
Table 2.15
Data for question 3
Parameter A B C
Self-assessment questions
c. The elimination of these drugs (half-life, t1/2) and e. List genetic and environmental factors that may
clearance (CL, and route). affect the disposition of these drugs (A, B, C,) in
d. Their potential for accumulation during chronic different individuals.
dosage (related to half-life and interval between
doses). The answers are provided on pages 703–706.
48