European Journal of
EurJ Clin Pharmacol (1982) 23:129 134
Effect of Chronic Oral Contraceptive Steroids
on Theophylline Disposition
K. M. Tornatore ~, R. Kanarkowski 2, T. L. McCarthy I, M.J. Gardner ~, A. M. Yurchak 1, and W. J. Jusko I
~Departmentsof Pharmacy,Pharmaceutics,and Medicine,Schoolsof Pharmacyand Medicine,State Universityof New Yorkat Buffalo,
New York, USA
2Departmentof Biopharmaceutics,MedicalCenterof PostgraduateEducation,Facultyof Pharmacy,Bydgoszcz,Poland
Summary. The effect of chronic oral contraceptive
(OC) usage on the disposition of theophylline was
examined. Aminophylline solution (4 mg/kg) was
given orally to 8 healthy female non-OC users and to
8 healthy women who were chronic ( > 6 months)
OC users. The OC user group had a significantly
lower total plasma clearance of theophylline than
women not using OC (35.1 _.+ 5.6 vs. 53.1 _+ 14.5 m l /
h/kg). The t,~ was also significantly prolonged in the
OC group (9.79 _+ 1.43 vs. 7.34 _+ 1.75 h) while the
volume of distribution was similar between the
2 groups. The serum ethinylestradiol (EE) concentra-
tions after oral OC administration were measured si-
multaneously. The apparent clearance of EE was
about 30% lower in the OC users. A significant posi-
tive correlation was found between the apparent
clearance of EE and the plasma clearance of the-
ophylline. The effects of OC are predominantly due
to chronic use with decreased elimination of both
theophylline and EE.
Key words: theophylline, ethinylestradiol; oral con-
traceptives, pharmacokinetics
Oral contraceptives (OC) are in common use as ap-
proximately 50 million women are currently employ-
ing this method of birth control [1]. They offer 2 pos-
sibilities for drug interactions. Some drugs such as
antibiotics have been found to impair OC efficacy by
interfering with enterohepatic circulation of estro-
gens [2]. More widespread is the inhibitory effect of
OC on the biotransformation of other drugs used
concurrently [1, 3]. Steroid hormones share the same
hepatic microsomal enzyme system responsible for
metabolism of certain drugs and thus competitive in-
Clinical Pharmacology
© Springer-Verlag 1982
hibition may occur [4]. In addition chronic estrogen
use has been associated with hepatotoxicity as an-
other mechanism of diminished drug metabolism
rate [5].
This study examines the effects of chronic OC
usage on the disposition of theophylline and ethinyl-
estradiol in normal women. The biotransformation
rate of theophylline exhibits marked variability be-
tween subjects as well as being affected by factors
such as age, drug interactions, and disease state [6].
Therefore, characterization of this drug in relation-
ship to OC use may assist the clinical choice of drug
dosages as well as lend insight into the mechanism of
OC effects on drug disposition in man.
Materials and Methods
Subjects
Sixteen healthy Caucasian female volunteers be-
tween the ages of i9 to 28 years were recruited for
this study. Eight women, who did not use oral con-
traceptives (OC) nor any other hormonal contracep-
tive method, comprised the control group. The re-
maining 8 women used oral contraceptives for at
least 6 months duration prior to the study. Two out
of the 8 OC users were previously taking a 50 ~tg
ethinylestradiol-0.5 nag norgestrel combination OC
(Ovral, Wyeth). The remaining 6 women switched to
Ovral for a 1 month time period with their physi-
cians' approval. The study was approved by human
investigation committees and carried out in a hospi-
tal setting.
All subjects were in normal health with no appar-
ent major organ disease. None of the volunteers used
any non-OC medications on a chronic basis and had
no known chemical exposure. These women were
0031-6970/82/0023/0129/$01.20
130 K. M. Tomatore et al.: Theophylline Disposition Following OC Steroids

Table 1, Characteristics of subjects aminophylline solution (IMS ®) in 200 ml of orange

Characteristic Non-users OC users
juice after an overnight fast. This dose was taken 1 h
after each woman in both groups received I dose of
Age range [years] 22-28 19-28 Ovral ®.
Mean age [years] 23.9 24.25 Subjects were asked to abstain from xanthine-
Total body weight (SD) a 53.5 61.1 containing products for 24 h prior to the study and
(5.1) (8.2) on the day of the study. Periodic blood samples were
Duration of OC use, [years] (SD) 0 4.40 collected via a heparin trap at 0, 0.5, 1, 2, 3, 5, 7, 11
(2.67) and 23 h after administration of theophylline. Serum
Tobacco use No No samples were frozen until assayed.
Marihuana use No No
Theophylline was extracted from 200 lxl of serum
using 5 ml of organic solvent (95% chloroform and
Alcohol use b (SD) 0.88 t.13
(0.35) (0.35)
5% isopropranol). After separation of the organic
phase containing theophylline and internal standard,
Caffeine usee (SD) 2.25 2.00
(1.67) (1.22)
fl-hydroxypropyltheophylline, the organic solvent
was evaporated using nitrogen gas. The remaining
Bilirubin [0-t.1 mg%]d (SD) 0.75 0.33
(o.17) (0.10) residue was reconstituted using 100 lxl of 0.4% acetic
acid which also served as the mobile phase. The the-
SGPT [0-38] (SD) 19 20
(8) (lO) ophylline samples were analyzed via high pressure
liquid chromatography using a Dupont HPLC Mod-
SGOT [0-461 (SD) 18 17
(5) (4)
el 841 with a Zipax ® SCX cation exchange column,
2.1 m m ID, with an UV photometer detector at
Alkaline Phosphatase [35-117] (SD) 55 52
(8) (14)
254 nm [9].

a Standard Deviation
b Coded as 0 = none, 1 = social, 2 = daily use of alcohol
c Number of cups of coffee or tea per day
Normal range in parentheses
not pregnant at the time of the study, were not heavy
drinkers, and did not use tobacco or marihuana (de-
fined as less than I joint 3 months prior to the study).
Studies on the OC group took place between Day 7
to Day 21 of the OC cycle while studies on the con-
trol group took place between Day 7 to 25 of the
menstrual cycle.
The 2 groups had similar characteristics as delin-
eated in Table 1. Mean age for both groups was ap-
proximately 24 years. Both groups had similar usage
patterns of alcohol and caffeine. Serum biochemistry
profiles (SMAC Autoanalyzer) and CBC with differ-
ential were obtained on all subjects prior to the study
and showed normal renal function, serum albumin,
serum bilirubin and other biochemical parameters.
Liver function tests, which have been shown to be
elevated in women using OC [7, 8], were within nor-
mal limits in both study groups. Total body weights
for both groups were within + 15% desirable body
weights as determined by body frames.
Theophylline
Each subject received a single oral dose of 4 m g / k g
(equivalent to approximately 3.1 m g / k g of theophyl-
line; 76.6% theophylline as assayed in this lab) of
Ethinylestradiol
Blood samples were collected at 0, 0.5, 1, 1.5, 2, 3, 4,
6, 8, 12 and 24 h after administration of Ovral ® with
200 ml of water. The serum ethinylestradiol (EE)
concentrations were measured by a previously devel-
oped RIA method [10, 11, 12]. 0.5 ml serum plus
0.5 ml water were extracted once with 5 ml hex-
ane :ethylacetate (75:25). Antibody to EE (R6-15
from Research Triangle Institute, NC) was used in
an initial solution of i : 10,000 which yielded a final
dilution of I :30,000. 17a-[6,7-3H(N)] ethinylestradiol
(57 Ci/mmol, New England Nuclear) was used in
the assay in the amount of 12.5 pg/tube. Individual
non-specific blank (zero h concentration values)
were subtracted from all subsequent values in the
group of non-OC users. The mean blank value from
this group (28 pg/ml) was subtracted from all con-
centration values in the group of OC users.
Calculations
A digital computer program was utilized to generate
the pharmacokinetic parameters of clearance (C1T),
terminal slope (2~), area under the concentration vs.
time curve (AUC), and tw. The post-absorptive phase
of the decline of theophylline from serum was mono-
exponential while that of EE was biexponential. The
terminal slope (~) was generated by fitting these
post-absorptive data points using log-linear least
squares regression analysis. Area under the serum
K. M. Tornatore et al.: Theophylline Disposition Following OC Steroids 131

concentration time curve was obtained via a combi- Table 2. Summary of theophylline pharmacokinetics in oral con-
nation of log trapezoidal integration and polynomial traceptive (OC) users and non-users
interpolation with inclusion of area extrapolated to Parameter (SD) Group
infinite time [13]. The total clearances (Cla-) were de-
Non-users OC users
termined from the result of Dose/AUC, while vo-
lume of distribution (VD) was generated from Dose/ tv2, h 7.34 9.79a
2z x AUC. These calculations assumed 100% bioa- (1.75) (1.43)
vailability of theophylline solution which has been ~, h - 1 0.100 0.072 a
previously demonstrated [15]. (0.026) (0.009)
Statistical analyses were performed using un- VD, 1/kg b 0.534 0.488
paired t-tests on the following pharmacokinetic pa- (0.073) (0.036)
rameters: CIT, 2z, t,~ and VD. Regression analysis and CIT, m l / h / k g b 53.1 35.1 ~
the correlation between the apparent clearance of (14.5) (5.6)
EE and the total clearance of theophylline was ob- a p <0.02
tained by the perpendicular least-squares method b VD and C1T are normalized for total body weight
[141. c p < 0.01

-~
~m
i0
Results E

z" 5
O
B
Theophylline I--
<
fr
I-

A typical plot of serum concentration of theophyl- z

I/J
2
(.)
line versus time is shown in Fig. 1. Peak serum con- Z
O
centrations were achieved within 2 h in most of the o I
l.u
subjects, demonstrating the rapid absorption of the- Z
_1

ophylline in solution. The decline of serum concen- ¢. 0.s

"1'-
trations in the post-absorptive phase was first-order. o,.
0
w
A summary of the pharmacokinetic parameters
(i. e. CI-r, t,~, VD and ~ ) for each group is compared in
Table 2. Total clearance which largely reflects the de- ,,=, 0.1
gree of hepatic biotransformation that the drug un- 0 25
dergoes is compared in Fig. 2. The control group had TIME, hours

a mean total clearance of 53.1 m l / h / k g with obvious Fig. 1. Serum theophylline concentration as a function of time fol-
variability (range of Cla- of 33.5 to 78.6 ml/h/kg). The lowing an oral dose of aminophylline in solution. Closed and
OC group exhibited a significantly lower clearance open circles are measured values for an OC user and non-user.
The solid lines are the least-squares fitting of points in the terminal
(35.1 ml/h/kg) than the control group. There was no phase
association seen between duration of OC use and
clearance in tile OC group. There was no significant
difference found in VD between the two groups e"
.m
(Table 2). Half-lives in OC users were prolonged (ap- 8O
.t=
proximately 9.79 h) when compared to the controls Q.
O
O
(7.34 h). Metabolism and distribution both influence
6o _ _ O
determination of the disposition t,5. It is apparent
OO
from these results that C1T, the index of this drug's t-

metabolic rate, is the major component influenced 4o _ 8 "1"

C
by use of OC. O •

(o 2O
Ethinylestradiol
The curves of the concentrations of EE in serum ver- ~- 0
sus time for a typical OC user and non-user are No Yes

shown in Fig.3. The descending portions of the OC Use

curves show a biexponential decline. The subjects' Fig.2. Total clearance of theophylline for OC users ( 0 ) and
peak serum EE levels were usually attained 1-1.5 h non-OC users (O). Horizontal bars denote mean values
132
6 500
Z _J
o
o 2e0
,.,.J
o lee
"~
tr,
50
I.-
M
}ze
>-
z 10
"v
w S
2
w I---
8 5 l8 15 20 25
TIME, h
Fig.3. Serum concentration of ethinylestradiol as a function of
time following a single 50 gg dose in an OC-nonuser (©) and dai-
ly 50 ~tg dosages in an OC-user (@)
after ingestion (in 2 cases after 2 h, in 1 case after
3 h). The peak concentration ranged between 94 and
232 pg/ml in the control group, and in the OC group
between 118 and 282 pg/ml. The average ( + SD) ap-
parent clearances of EE were 998 (402) and 653
(390) m l / h / k g in the control group and OC users.
The relationship between the apparent clearance
of EE and the total clearance of theophylline is
shown in Fig.4. A significant positive correlation
(r = 0.500, 0.01 < p < 0.05) was found.
Discussion
Theophylline Disposition
Chronic use of OC reduces the total clearance of the-
ophylline by 34% on average and increases the t,~ by
a similar degree. These alterations in theophylline
pharmacokinetics are largely caused by diminished
biotransformation as the drug given in oral solution
is completely and rapidly absorbed [15] and approxi-
mately 90% of a dose is metabolized by the hepatic
microsomes [16]. While the present study involved
use of single doses of theophylline, it is likely that
OC users who require chronic dosing with this bron-
chodilator will also require lower than normal doses.
Extrapolation of an average reduction in starting
dose of 33% seems reasonable, but differences in the
degree of inhibition of metabolism may occur when
larger body loads of theophylline are present and be-
cause of the potential for a small degree of nonlinear
disposition of theophylline [17]. However, other fac-
tors may also complicate the effects of OC. The pro-
K. M. Tornatore et al.: Theophylline Disposition Following OC Steroids
Z
80 ¢.
_J
-r
Q.
o 60
u/
I
Oo
< E
<
m
,.I
20
O
o
I.-
APPARENT CLEARANCE of EE, m l l h l k g
Fig.4. Relationship between total clearance of theophylline and
apparent clearance of ethinylestradiol. The line was obtained by
the method of least-squares fitting when both variables contain er-
ror yielding a slope of 0,033 and an intercept of 16,5
duct used in our studies contains a moderate quanti-
ty of estrogen. If the data in Fig. 4 is treated as a type
of dose-response plot with estrogen clearance in-
versely proportional to its AUC, then it is likely that
lower and higher potency estrogen products may
produce different degrees of metabolic inhibition.
This is supported in the literature as decreased clear-
ance of antipyrine occurs in women using either low
or high e~trogen products [18, 19]. In addition, differ-
ences in effects can result from the time-course of
OC use. This was evaluated with aminopyrine by
Herz et al. [20] who found that women who were just
starting OC had a progressive increase in tv~over the
first 21 days. Chronic OC users showed a doubled t~
while normal women not using OC had no changes
in t,~ at different stages in their menstrual cycle. The
potential variability in OC effects on theophylline
disposition during chronic dosing thus warrants se-
rum concentration monitoring to assure safe and
nontoxic therapy.
Ethinylestradiol
A good correlation was observed between apparent
clearance of EE and Cla- of theophylline (Fig.4).
Unless chronic use of OC causes a Michaelis-Men-
ten type of saturation in EE elimination, these find-
ings plus the evidence for the variety of drugs affect-
ed suggest that a generalized reduction in oxidation
capability concomitantly decreases both EE and
theophylline clearance.
In our study, EE clearance in OC users averaged
35% less than that of non-OC users. The difference
did not attain statistical significance (0.2 < p < 0.1)
K. M. Tornatore et al.: Theophylline Disposition Following OC Steroids
because of large inter-individual variability. A larger
group of subjects may better delineate such differ-
ences in clearance.
Further examination of the relationship between
EE and theophylline clearances provides a physio-
logical meaning of the y intercept in Fig.4. Because
of the fact that EE is almost completely eliminated
by non-renal pathways [21], the y intercept of the
graph should approximate the renal clearance of the-
ophylline. This was the case as an intercept of
16.5 m l / h / k g or 15.8 ml/min was found which is
consistent with previously reported [22] values of
renal theophylline clearance (about 6-16 ml/min).
Nature of OC Effects
Several drugs exhibit reduced clearances in OC us-
ers. These include chlordiazepoxide [23], antipyrine
[18, 19, 24, 25], aminopyrine [20, 26], and caffeine
[27]. Lower clearances of theophylline were also not-
ed in women smokers who used OC in comparison
with non-OC, smoking females [6]. Theophylline me-
tabolism has been attributed to the P-448 hepatic
microsomal system in animals [28] and also in man
(owing to its sensitivity to cigarette smoke induction
[29, 30], and limited inductive effects caused by
phenobarbital [31]. Thus the common effects of OC
on drug substrates metabolized by P-450 (antipyrine)
and P-448 microsomal systems suggest that OC pro-
duce a generalized diminishment in oxidative path-
ways of biotransformation.
Experimental results from animal systems have
demonstrated various types of hepatic effects from
OC administration. Estrogens and progesterones act
as metabolic inhibitors, including reducing the activ-
ity of the P-448 cytochrome which can subsequently
be induced by 3-methylcholanthrene [4, 32]. Large
doses of norethylnodrel and mestranol given to ani-
mals have resulted in stimulation of ethylmorphine
metabolism while competitive inhibition occurred
when these compounds were added in vitro to en-
zyme preparations [19]. More recent studies found a
reduced relative rate of synthesis of the cytochrome
P-450 apoprotein which suggests that a chronic ef-
fect occurs as well [32]. Thus extrapolation of animal
data to man must be done cautiously as interstudy
differences in animal spedes, sex, and steroid type
and doses may account for some of the differences
found. Our studies were designed to assess the ef-
fects of multiple versus single dose effects of OC and
thus best reflect the occurrence of a chronic effect on
hepatic function.
Acknowledgements. Supported in part by G r a n t
N o . 2 0 8 5 2 f r o m the N a t i o n a l I n s t i t u t e s o f G e n e r a l
133
Medical Sciences, NIH. Ethinylestradiol antiserum
was kindly provided by Dr. C.E. Cook of Research
Triangle Institute, NC, USA.
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Received: November 25, 1981
accepted in revised form: February 16, 1982
William J. Jusko, Ph. D.
Division of Clinical Pharmacy Sciences
State University of New York at Buffalo
319 Cooke Hall
Buffalo, NY 14260, USA