FAR 381

Pharmacokinetics

Werner Cordier
PhD, PGCHE
Department of Pharmacology

Tel: (012) 319-2521 werner.cordier@up.ac.za

 Pharmacokinetics
Study of time course of drug concentration in the body

“What the body does to the drug”

• Aspects of drug input and output (LADMET)
– (Liberation)
– Absorption
– Distribution
– Metabolism
– Excretion
– (Toxicity)
Pharmacokinetic profile
 The ADME scheme
Non-discrete events that can occur simultaneously

Absorption: movement of the drug from the site of administration to the

blood circulation

Distribution: diffusion or transport of drug from intravascular space to

extravascular space

Metabolism: chemical conversion or transformation of drugs into

compounds for easier elimination

Excretion: elimination of unchanged drug or metabolite from body via

excretory system
The ADME scheme

Absorption
 Absorption
Movement of solubilised drug from administration site into
systemic circulation, across biological membranes

• Absorption affects … of action

– Onset
– Duration
– Intensity

• Transport classified according to energy dependency

into two major types
– Passive (does not require energy)
– Active (requires energy)
 Passive transport
• Drug molecule penetrates lipid bilayer
– Along concentration gradient
– No cellular energy used

• Along concentration gradient

– Movement from high to low concentration

• Different subtypes
– Simple diffusion
Most frequently used by drugs
– Facilitated diffusion
– Filtration and osmosis
– Bulk flow
 Passive transport
(simple diffusion)

• Direct movement of drug through semi-permeable

membrane until equilibrium reached
– Along concentration gradient
– No cellular energy used
High
Concentration gradient

Low
 Passive transport
(physicochemical factors affecting simple diffusion)

• Solubility
– Lipophilic molecules pass through lipid bilayers more
easily than hydrophilic molecules

• Size
– Small, low-molecular weight molecules pass through
lipid bilayer more easily than large ones

• Ionisation
– Ionisation state alters solubility of compounds
 Passive transport
(solubility affects passive diffusion)

• Lipophilic molecules
– Dissolve easily in lipids
• Tend to cross lipid bilayers freely
• Generally higher permeation into cells
– Needs to dissolve slightly in water to be absorbed
• Otherwise cannot pass through hydrophilic heads
– Extremely lipophilic molecules Hydrophilic
• Cannot dissolve in aqueous head
compartments
Lipophilic
• Reduced absorption tail

Hydrophilic
head
 Passive transport
(solubility affects passive diffusion)

• Hydrophilic molecules
– Dissolve easily in water due to hydrogen bonds
– Cannot dissolve in lipophilic compartments
• Does not pass through lipophilic tails
– Reduced absorption
 Passive transport
(ionisation affects diffusion)

Weak acids and bases ionise at different pH ranges

Ionised/charged molecules
Unionised/uncharged Positive or negative charge
molecules Tend to form hydrogen bonds
More lipophilic Less lipophilic
Higher membrane Low membrane permeability
permeability
 Passive transport
(ionisation affects diffusion)

Ionisation is dependent on pH of environment, pKa of drug

and status as weak acid or base
• pKa
– pH where drug is
equally ionized and
unionized

• Weak acids
– Ionized if pKa < pH

• Weak bases
– Ionized if pKa > pH
 Passive transport
(ionisation affects simple diffusion)
Unionised molecules
Move across membranes to other systems
Action (if possible) more dispersed

• pH partitioning effect and

cellular retention
– Important for drugs that need
to accumulate in specific
location to exert mechanism
of action (e.g. local
anaesthetics)

Ionised molecules
Get retained within their environment
Action exerted (if possible) at that site
 Passive transport
(ionisation affects simple diffusion)

Although pH partitioning is important, it is not the major

determinant of GIT absorption

• Small intestines have the best absorptive surface

– Stomach’s absorptive surface small relative to intestines
• Not ideal for aborption
– Intestinal absorptive surface higher because of villi and
microvilli
– Most of GIT absorption occurs in small intestines,
regardless of ionisation state
 Passive transport
(facilitated diffusion)

• Drug molecule transported across bilayer

– Along concentration gradient
– No cellular energy used
– Facilitators (carriers/transporters) required

Transporters Carriers
 Active transport
• Drug molecule penetrates lipid bilayer
– Against concentration gradient
– Cellular energy (ATP) used
– Facilitators (carriers/transporters) required

• Against concentration gradient

– Movement from low to high concentration

• Two types classified by usage of cellular energy

– Primary (direct usage of ATP)
– Secondary (indirect usage of ATP)
 Active transport
(primary)

Direct ATP usage for transport of molecules

ADP

ATP

ATP-
binding
site
ATP converted to
ATP binds to ADP, releases energy ADP free
receptor for transport
 Active transport
(secondary)

Transport occurs via electrochemical gradient established

by primary transport (if ions transported)

Molecule transported along

with ions against gradient
(indirectly uses energy)
 Specialized transport
(active and facilitated transport)

• Specific towards molecule

– Only specific chemical structures
recognized by facilitators

• Saturable system Only transported once

facilitator available
– Finite amount of facilitators
– Transported if facilitators available
– If none available, no transport
occurs until available

• Types of drugs transported

– Generally those that aren’t diffusable or hydrophilic
 Bioavailability
Fraction of administered drug that reaches systemic
circulation unchanged

• Relative comparison
– IV always 100% bioavailable

𝐀𝐔𝐂𝐨𝐫𝐚𝐥
𝐁𝐢𝐨𝐚𝐯𝐚𝐢𝐥𝐚𝐛𝐢𝐥𝐢𝐭𝐲 =
𝐀𝐔𝐂𝐈𝐕

• Factors affecting bioavailability

– All ADME processes may alter
drug’s presence
 Quiz time
1. Mario can use enrofloxacin (lipophilic) or gentamycin
(hydrophilic). Which one crosses membranes easily?

A. Enrofloxacin
B. Gentamycin

2. Peach is taking aspirin (pKa 3.5). In which part of the

GIT will it be most likely be unionised?

A. Oesophagus
B. Stomach
C. Small intestine
D. Large intestine
 Quiz time
3. Is Peach’s aspirin more likely to be absorbed in an
ionised or unionised state?

A. Ionised
B. Unionised

4. Luigi is taking amino acid supplements, which uses

active transport. Which one of the following is true?

A. No energy, against a concentration gradient

B. No energy, along a concentration gradient
C. Uses energy, against a concentration gradient
D. Uses energy, along a concentration gradient
The ADME scheme

Distribution
 Distribution
Movement of drug from systemic circulation throughout the
body to, ideally, the site(s) of action

• Affected by the physicochemical properties of the drug

– Determines extent of distribution
– Widespread, organ-specific or localised
– Spreads to major fluid compartments of the body
• Plasma (circulatory fluid)
• Interstitial fluid (fluid between cells)
• Intracellular fluid (fluid in cells)
– Circulatory system is the first compartment to which
distribution occurs
 Transport in circulatory system
Drug dissolves in plasma and/or binds to plasma proteins

• Plasma proteins in blood

– Albumin
– Lipoproteins
– Acid glycoprotein
– α, β and γ-globulin

• Function of albumin
– Maintains colloidal osmotic pressure of blood
– Carriers for hydrophobic molecules
– Most important protein involved in drug binding
 Transport in circulatory system
(plasma protein binding: free and bound fractions)

Hydrophilic drug Lipophilic drug dissolves to

transported lower degree in plasma
Free fraction
freely in plasma (until aqueous compartment
available in
(can dissolve) saturated)
plasma

Undissolved drug binds

to hydrophobic pockets
Hydrophobic of plasma protein as
pockets of Bound fraction gets bound fraction
plasma protein released as free
unbound (empty) fraction is excreted
(replaces free
fraction)
 Transport in circulatory system
(differences between free and bound fractions)

Free fraction pharmacologically active Bound fraction pharmacologically inert

Elicits biological effect
Transported across cellular systems
Gets metabolised
Gets excreted
No biological effect because cannot fit into
active sites of drug targets
Does not get transported
Does not get metabolised
Is not excreted and not filtered by kidneys
 Transport in circulatory system
(clinical implications of plasma protein binding)

• Plasma protein-bound drugs have clinical implications

– If highly bound, free fraction is decreased
• Lower activity, distribution, metabolism, excretion
– If plasma proteins saturated/depleted
• Increased free fraction
– Drug displacement may occur during drug interactions
Drug-drug interaction
Drugs with higher affinity for plasma
proteins will eject lower affinity drugs,
increasing free fraction
 Transport in circulatory system
(factors that affect plasma protein binding)

• Plasma protein concentration

– Amount available to be bound
– Can be saturated if drug concentration high enough

• Free drug concentration

– Influences displacement of bound drug to maintain
equilibrium in plasma

• Affinity for binding sites

– Influences how easily drugs bind to plasma proteins
– Drugs with high affinity may displace low affinity drugs
 Body fat partitioning
Body fat consists of a large, non-polar compartment with a
poor blood supply

• Drug accumulation into body fat

– Only drugs with high lipophilicity accumulate easily
– Chronic administration of lipophilic drugs (e.g.
anaesthetics), or those with low metabolic clearance,
may accumulate
– Important in obese patients
– Explains lasting toxicity of several lipophilic drugs
 Blood-brain barrier
Continuous layer of endothelial cells joined by tight junctions
and surrounded by pericytes

• Protective barrier between blood supply and central

nervous system
– Prevents toxin entry
into brain
Blood-brain barrier
(transport across blood-brain barrier)

Passive diffusion
Water, lipophilic molecules/drugs and some gases

Selective transport with facilitators

Drugs that fit a transporter or carrier
Amino acids and glucose

Functionally-permeable areas
Certain regions more permeable than others
Chemo-emetic trigger zone (toxin sensor)

Elements that increase permeability

(allows access to inaccessible molecules)
Certain molecules (e.g. bradykinin and enkephalins)
Barrier inflammation and stress
 Volume of distribution (Vd)
Measure of drug’s distribution in the body

𝐭𝐨𝐭𝐚𝐥 𝐚𝐦𝐨𝐮𝐧𝐭 𝐨𝐟 𝐝𝐫𝐮𝐠 𝐢𝐧 𝐛𝐨𝐝𝐲 (𝐦𝐠)

𝐕𝐝 =
𝐝𝐫𝐮𝐠 𝐂𝐩 (𝐦𝐠/𝐋)

• Theoretical volume (in L) into which administered drug

has to be dissolved to yield plasma concentration (Cp)
– No reference to actual volume of body or its fluids
– Indication of lipophilicity and plasma protein binding
– Inverse relationship between Vd and Cp
– Direct relationship between Vd and half-life (t½)
 Volume of distribution (Vd)
Low Vd (<15 L)
Mostly confined to systemic circulation
Higher Cp
Faster metabolism/elimination
e.g. penicillin

Before administration High Vd (>40 Vd)

Drug not found anywhere Spread throughout the body
Lower Cp
Slower metabolism/elimination
e.g. tricyclic antidepressants
 Volume of distribution (Vd)
(practical example)

300 mg bolus administered, yielding a Cp of 10 mg/L

𝐭𝐨𝐭𝐚𝐥 𝐚𝐦𝐨𝐮𝐧𝐭 𝐨𝐟 𝐝𝐫𝐮𝐠 𝐢𝐧 𝐛𝐨𝐝𝐲 (𝐦𝐠)

𝐕𝐝 =
𝐝𝐫𝐮𝐠 𝐂𝐩 (𝐦𝐠/𝐋)
𝟑𝟎𝟎 𝐦𝐠
𝐕𝐝 =
𝟏𝟎 𝐦𝐠/𝐋
𝐕𝐝 = 𝟑𝟎 𝐋

Thus this drug displays wide distribution

 Volume of distribution (Vd)
(used to determine the loading dose)

Higher dosage that is administered at achieve the

target Cp and steady state earlier
 Quiz time
1. Toad is taking clozapine (Vd = 526 L). What would the
solubility of this drug be?

A. Hydrophilic
B. Lipophilic

2. Yoshi’s streptozocin has caused hypoalbuminaemia.

Which one of the following implications is NOT true?

A. Increased free fraction of lipophilic drugs

B. Increased activity of lipophilic drugs
C. Reduced metabolism of lipophilic drugs
D. Increased plasma protein binding of lipophilic drugs
The ADME scheme

Metabolism
 Metabolism
Chemical conversion of substrates to metabolites

• Metabolism of drugs by enzymes

– Body’s detoxification process of molecules
– Increases hydrophilicity to allow for the removal of
unwanted chemicals in urine
– Occurs mainly in liver, but also intestines, plasma, lungs
– Can be catabolic (break-down) or anabolic (build-up)
– Phase I and/or phase II metabolic reactions

• Two prominent models on enzymatic conversion

– Lock-and-key model
– Induced fit model
 Anabolic

Metabolism Catabolic
Substrate (models of enzymatic activity)
Lock-and-key model
Shape of substrate and enzyme’s active site are complementary to one another

Active site Substrate-enzyme complex Metabolites

Induced-fit model
Active site can undergo conformational changes (to certain degree) to accommodate substrates
Shape of active site becomes complementary after binding to substrate
 Metabolism
(possible outcomes)

• Metabolism may
– Deactivate active drugs to inactive metabolites
– Activate inactive pro-drugs to active metabolites
– Convert active drugs to active metabolites
– Form reactive, toxic metabolites or carcinogens
– Important! Each metabolite may produce different effect

Inactive pro-drug Active metabolite Toxic metabolite

Cyclophosphamide Phosporamide mustard Acrolein

Will not produce Conversion to active Conversion to reactive

required biology activity metabolite which produces metabolite which produces
required biology activity unwanted adverse effects
 Metabolism
• Lipophilic drugs most often metabolised
– Can cross membrane to reach enzymes
– Easily reabsorbed in kidney due to passive diffusion
– Reactions create more reactive, hydrophilic
metabolites that can be excreted through the kidney

• Hydrophilic drugs generally not metabolised

– Unlikely to cross membranes, unless transported
– Hydrophilicity allows for better urinary excretion
 Metabolism
(phase I reactions)

Molecule made more reactive for subsequent metabolism

• Cytochrome P450 monooxygenase (CYP450) enzymes

– Found primarily in liver, but also GIT and other tissues
– Microsomal enzymes that are haem proteins
– Enzymes are related, but each distinct in structure
– Some substrate specificity overlaps, but differs in
sensitivity and rate of conversion
Warfarin
CYP1A1
Primary CYP2C9 CYP1A2 Secondary
metabolism CYP2C19 metabolism
CYP3A4
 Metabolism
(phase I reactions)

CYP450s are a large family of enzymes, and are grouped

according to their homology
 Metabolism
(approximate percentages of drugs metabolism by CYP450 enzymes)

CYP3A4 is the largest contributor to drug metabolism

CYP2E1 CYP1A1/2
4% 11% CYP2A6
CYP3A4/5
36% 3%
CYP2B6
3%

CYP2D6
19%

CYP2C19 CYP2C8/9
8% 16%
 Metabolism
(phase I reactions)

• Oxidation reactions (primary)

– Addition of oxygen molecule to form hydroxyl group
– Mostly CYP450 enzymes, but others also exist

• Reduction reactions
– Addition of electrons
– Mostly CYP450 enzymes, but others also exist

• Hydrolysis reactions
– Cleavage of molecule through addition of water
– Does not involve hepatic microsomal enzymes
 Metabolism
(phase II reactions)

Anabolic conjugation of molecule with large, hydrophilic

group to form less lipophilic, more hydrophilic molecule for
excretion

• Occurs primarily in liver, but also lungs and kidneys

– Glucoronidation (primary)
– Sulfation
– Acetylation
– Amino acid conjugation
– Glutathionation
 Metabolism
(phase I and II)

Phase I or II metabolism do not always occur separately or

sequentially, and can thus be independent

Glucuronidation

Acetaminophen Sulfation

Glutathione
CYP-mediated hydroxylation
conjugation
and rearrangement

Phase I Phase II

NAPQI Phase II conjugates

 Metabolism
(inhibition of enzymes)

• Inhibition of CYP450 enzymes decreases enzyme

activity
– Direct enzyme inhibition (e.g. fluoxetine)
• Results in immediate changes to metabolism
– Reduced enzyme expression (e.g. grapefruit)
• Requires hours to days to alter enzyme levels due to
genetic alterations

• Induction of CYP450 enzymes increases activity

– Increased enzyme expression (e.g. rifampicin)
• Requires hours to days to alter enzyme levels due to
genetic alterations
 Metabolism
(first-pass metabolism)

Sum of all metabolic effects in GIT and liver that reduce Cp

of drug before reaching systemic circulation

• Blood flow to the systemic circulation

– Blood flow from intestines first goes to the liver
– After liver, distributed to the rest of the systemic
circulation
 Four major enzyme Parent compound
systems involved:
• GIT lumen
Metabolism Metabolite
• GIT wall (first-pass metabolism)
• Bacterial Travel direction
• Hepatic

Hepatic
artery 5. Parent compound and
metabolites travel with hepatic vein
to rest of body through systemic
2/4. Enzymes circulation
degrade
compounds

3. Portal vein
from GIT absorbs
parent compound
and metabolites
Bile
1. Parent drug enters duct
the intestines

Intestines
 Metabolism
(clinical implications of first-pass metabolism)

• Higher dosage required with oral administration

– Dosage increased to counteract the loss through
metabolic degradation

• Inter-individual variation in enzyme systems

– Genetic variability allows for unpredictable first-pass
metabolism effects

• Susceptibility to drug-drug interactions

– Drugs affecting enzymes involved in first-pass
metabolism may influence bioavailability easily
 Quiz time
1. Wario’s nevirapine undergoes first-pass metabolism.
Which enzyme system is NOT involved in this effect?

A. Enzymes from intestinal bacteria

B. Enzymes of the GIT lumen
C. Enzymes of the liver
D. Enzymes of the kidney
E. Enzymes of the GIT wall
 Quiz time
2. Waluigi is taking cimetidine (CYP3A4 inhibitor). How
will this affect CYP3A4 substrates?

A. Increased activation of CYP3A4 pro-drugs

B. Decreased plasma concentration of CYP3A4 substrates
C. Increased risk of adverse effects of CYP3A4 substrates
The ADME scheme

Excretion
 Excretory systems
Removal of drug or metabolites through excretory organs

• Main routes of excretion

– Kidneys (as urine) Primary excretion route
– Hepatobiliary system (as bile and faecal matter)
– Lungs (as volatile gasses)

• Negligible excretion routes

– Milk, tears, saliva, semen and sweat
– May be important for side effects
 Excretion
(renal system)

Plasma filtered by kidneys to remove small hydrophilic

molecules

• Mechanisms underlying renal drug excretion

– Glomerular filtration
– Active tubular secretion
– Passive diffusion across tubular epithelium
 Excretion
(renal system)

• Glomerular filtration
– Large molecules cannot cross glomerular membrane
(unless damaged)
– Only free fraction is filtered, not bound fraction

• Active tubular secretion

– Carried-mediated transport that may be saturated
– Results in highest amount drug clearance

• Passive diffusion across tubular epithelium

– Lipophilic drugs reabsorbed into systemic circulation
– Affected by ionization state of drug
 Excretion
(biliary system)

Large, charged or amphipathic drugs may be excreted by

hepatocytes into duodenum

• Drugs excreted in bile

– Usually hydrophilic phase II conjugates, mainly
glucoronides
– Eventually excreted as faecal matter

• Mechanisms underlying biliary excretion

– Passive diffusion
– Facilitated diffusion and active transport
 Excretion
(enterohepatic circulation in biliary system)

Reversal of metabolic conjugation of drugs through

bacterial enzymes

• Results in
– Drug stays active for much longer
– May cause hepatotoxicity
– Interruption in cycle (e.g. destruction of gut bacteria)
may interrupt cycle and lead to concentration
fluctuations
 Excretion
(enterohepatic recirculation in biliary system)

6. Some active drug may return

Hepatic artery
to systemic circulation to exert
biological activity

Phase II metabolite 1/7. Active drug enters

liver through hepatic artery
for metabolism

Liver 5. Active drug reabsorbed

through portal vein and
metabolic cycle repeats
3. Phase II conjugate
excreted through 2. Phase II metabolism Intestines
bile duct into converts active drug to
intestines phase II conjugate

4. Bacterial enzymes cleave phase II

conjugate back to active drug
Pharmacokinetic
concepts
 Half-life (t½)
Time necessary for the drug’s Cp to decrease by half

Used to determine steady state and dosing interval

 Quiz time
1. Bowser’s aspirin (t½ = 20 minutes) Cp is 60 µg/mL. How
much is left after 60 minutes from this measurement?

A. 3.125 µg/mL
B. 5 µg/mL
C. 7.5 µg/mL
D. 15 µg/mL
E. 20 µg/mL
F. 30 µg/mL
 Half-life (t½)
(used to determine dosing parameters)

• Provides an index for

– Time-course of drug accumulation
• If drug continuously administered, >90% of steady
state concentration (Css) achieved after four-to-five t½
– Time-course of drug elimination
• If drug administration stopped, <10% of Css left after
four-to-five t½
– Dosing interval
• Chosen so that Css remains in therapeutic range
(above minimum therapeutic concentration, below
minimum toxic concentration)
 Half-life (t½)
(factors influencing)

• Elimination rate
– Time taken for drug to be eliminated from body
– Combination of metabolism and excretion pathways

• Volume of distribution
– Bound fraction does not get eliminated easily
– Needs to be at site of metabolism and excretion to be
processed

• Patient factors
– Genetic profile
– Drug or food interactions
 Half-life (t½)
(clinical implications)

Clinical implication Short t½ Long t½

Duration of action Short Long
(depends on mechanism)
Dosing frequency Increased Decreased
Compliance Typically lower Usually higher
Steady state Reached earlier Reached later
Side effects Disappear quicker Disappears slowly
(short washout) (long washout)
 Steady state
Steady state achieved when rate of drug absorption equals
drug elimination, and Cp plateaus

Css is
concentration
where steady
state is reached
with specific
dosing
parameters
Dosed so that steady state is
reached within therapeutic range

Dependent on t½
Reached within 4 – 5 x t½ if administered as it should be
Works for first-order kinetic drugs
 Steady state
• Drugs with short t½
– Steady state achieved earlier

• Drugs with long t½

– Steady state achieved later

• Missed dosage
– Can result in Cp falling below therapeutic range for a
period of time
– Clinically insignificant in most cases
– Affects drugs with narrow therapeutic index greatly
 First-order kinetics
Constant fraction of drug eliminated per unit of time

• Important
– t½ is constant, and concentration-independent
– Doubling dosage, doubles Cp
First-order kinetics
• Undergoes exponential decline
– Most drugs follow first-order kinetics
– In normal circumstances, drug
accumulation will not occur
– Predictable profiles
– Drug will in essence not be cleared fully,
but reaches low enough concentration
to be ‘essentially gone’
 Zero-order kinetics
Constant amount of drug eliminated per unit of time

Small dose Large dose

• Important
– t½ is variable and concentration-dependent, due to
saturable kinetics
– High Cp require more time to clear, thus t½ increases
 Zero-order kinetics
• Undergoes linear decline
– Few drugs (e.g. phenytoin, alcohol)
– Saturable parameters (e.g. enzymes, transporters)
• ADME processes are rate-limiting factors
– Will be cleared completely after enough time

Small dose

Large dose
 Quiz time
1. Daisy is taking paracetamol (t½ = 3 hours). How long
would you expect it to take to reach steady state?

A. 7 to 10 hours
B. 8 to 11 hours
C. 9 to 12 hours
D. 10 to 13 hours
E. 11 to 14 hours
F. 12 to 15 hours
 Quiz time
2. Boo’s warfarin follows zero-order kinetics. How does
elimination occur?

A. Constant amount per unit time

B. Constant fraction per unit time
 Try it by yourself
1. Compare the ionisation state and permeability of
diazepam (pKa 3.3, weak base) as it passes through the
stomach and intestinal tract. (2)

2. Oxcarbazepine is a pro-drug that requires metabolic

activation. What does this mean? (½)

3. Paracetamol has an oral bioavailability of 80%.

a. Define bioavailability. (½)
b. Describe the cause of reduced bioavailability. (1)

4. Nevirapine undergoes extensive enterohepatic

recirculation. Explain the steps involved in this. (2)