MODULE 5

Anatomy and Physiology of Liver

The liver is the major organ responsible for drug metabolism. However, intestinal tissues, lung, kidney, and skin
also contain appreciable amounts of biotransformation enzymes. Metabolism may also occur in other issues to a
lesser degree depending on drug properties and route of drug administration.
The liver is both a synthesizing and an excreting organ. The basic anatomical unit of the liver is the liver lobule,
which contains parenchymal cells in a network of interconnected lymph and blood vessels. The liver consists of
large right and left lobes that merge in the middle. The liver is perfused by blood from the hepatic artery; in
addition, the large hepatic portal vein that collects blood from various segments of the GI tract also perfuses the
liver. Bromsulphthalein is a chemical used in the determination of the secretory function of the liver.
The hepatic artery carries oxygen to the liver and accounts for about 25% of the liver blood supply. The hepatic
portal vein carries nutrients to the liver and accounts for about 75% of liver blood flow. The terminal branches
of the hepatic artery and portal vein fuse within the liver and mix with the large vascular capillaries known as
sinusoids.
Blood leaves the liver via the hepatic vein, which empties into the vena cava. The liver also secretes bile acids
within the liver lobes, which flow through a network of channels and eventually empty into the common bile
duct. The common bile duct drains bile and biliary excretion products from both lobes into the gallbladder.
Factors Influencing Drug Metabolism
Biotransformation processes are affected by many factors:
1. Drug metabolism in the liver has been shown to be flow and site dependent. Some enzymes are
reached only when blood flow travels from a given direction. The quantity of enzymes involved in metabolizing
drugs is not uniform throughout the liver. Consequently, changes in blood flow can greatly affect the fraction of
drugs metabolized. Clinically, hepatic diseases, such as cirrhosis, can cause tissue fibrosis, necrosis, and hepatic
shunt, resulting in changing blood flow and changing the bioavailability of drugs. For this reason, and in part
because of genetic differences in enzyme levels among different subjects and environmental factors, the half-
lives of drugs eliminated by drug metabolism are generally very variable.
2. The functioning of metabolic enzyme systems may be quite different at the extremes of age.
Historically, neonates were at risk of toxicity from chloramphenicol because they do not conjugate this drug
efficiently.
3. The social habits of a patient may affect drug elimination. Alcohol use and smoking may
increase the hepatic clearance of some drugs by inducing metabolic enzymes.
4. Disease states such as cirrhosis and conditions that decrease liver blood flow (e.g., heart failure)
significantly affect drug metabolism.
5. Concomitant drug use may affect drug metabolism. Certain drugs, such as phenytoin and
phenobarbital, may induce hepatic enzymes, whereas other drugs, such as cimetidine and valproic acid, may
inhibit hepatic enzymes.
6. The ability to metabolize drugs may vary considerably due to individual genetic makeup.
Genetic polymorphism can affect the individual response to a drug. A popular example, investigators have also
shown that two distinct subpopulations have varying capacities for drug acetylation (Phase II reaction) as a
result of genetic polymorphism. Rapid acetylators have a greater rate of elimination for drugs such as isoniazid
and hydralazine. For slow acetylators, the usual doses of these agents may result in excessive plasma
concentrations and, therefore, increased drug toxicities.

Hepatic Enzymes Involved in the Biotransformation of Drugs

Mixed-Function Oxidases (MFOs)
The liver is the major site of drug metabolism, and the type of metabolism is based on the reaction involved.
The enzymes responsible for oxidation and reduction of drugs (xenobiotics) and certain natural metabolites,
such as steroids, are monoxygenase enzymes known as mixed-function oxidases (MFOs).

The mixed-function oxidase enzymes are structural enzymes that constitute an electron-transport system that
requires reduced NADPH (NADPH2), molecular oxygen, cytochrome P-450, NADPH– cytochrome P-450
reductase, and phospholipid.

Enzyme responsible for transferring an Oxygen atom to the substrate is called Cytochrome P-450. Cytochrome
P-450 is a heme protein with iron protoporphyrin IX as the prosthetic group. Cytochrome P-450 is the terminal
component of an electron-transfer system in the endoplasmic reticulum and acts as both an oxygen- and a
substrate- binding locus for drugs and endogenous substrates in conjunction with a flavoprotein reductase,
NADPH– cytochrome P-450 reductase.

Other Important Enzymes involved in Drug Biotransformation

A few enzymatic oxidation reactions involved in biotransformation do not include the CYP monooxygenase
enzyme system.
1. Monoamine oxidase (MAO) that deaminates endogenous substrates including neurotransmitters
(dopamine, serotonin, norepinephrine, epinephrine, and various drugs with a similar structure);
2. Alcohol and aldehyde dehydrogenase in the soluble fraction of liver are involved in the
metabolism of ethanol
3. Xanthine oxidase which converts hypoxanthine to xanthine and then to uric acid. Drug
substrates for xanthine oxidase include theophylline and 6-mercaptopurine. Allopurinol is a substrate and
inhibitor of xanthine oxidase and also delays metabolism of other substrates used in the treatment of gout.

Drug Biotransformation Reactions

The hepatic biotransformation enzymes play an important role in the inactivation and subsequent elimination of
drugs that are not easily cleared through the kidney. For most biotransformation reactions, the metabolite of the
drug is more polar than the parent compound. A lipid-soluble drug crosses cell membranes and is easily
reabsorbed by the renal tubular cells, exhibiting a consequent tendency to remain in the body. In contrast, the
more polar metabolite does not cross cell membranes easily, is filtered through the glomerulus, is not readily
reabsorbed, and is more rapidly excreted in the urine.
For some drugs, the metabolite may be pharmacologically active or produce toxic effects. Prodrugs are
inactive and must be biotransformed in the body to metabolites that have pharmacologic activity. Initially,
prodrugs were discovered by serendipity, as in the case of prontosil, which is reduced to the antibacterial agent
sulfanilamide. More recently, prodrugs have been intentionally designed to improve drug stability, increase
systemic drug absorption, or prolong the duration of activity. For example, the antiparkinsonian agent
levodopa crosses the blood-brain barrier and is then decarboxylated in the brain to L-dopamine, an active
neurotransmitter. L-Dopamine does not easily penetrate the blood-brain barrier into the brain and therefore
cannot be used as a therapeutic agent.

Pathways of Drug Biotransformation

Pathways of drug biotransformation may be divided into two major groups of reactions, phase I and phase II
reactions.
1. Phase I, functionalization or asynthetic reactions, include oxidation, reduction, and hydrolysis.
2. Phase II, or synthetic reactions, include conjugations.

Some Common Drug Biotransformation Reactions

Phase I Reactions
Usually, phase I biotransformation reactions occur first and introduce or expose a functional group on the drug
molecules.
• Drugs are oxidized or reduced to a more polar form - excretable form
• In some drugs, the products of Phase I reactions are often more chemically reactive and hence,
more toxic or carcinogenic than the parent drug (e.g., Acetaminophen)

The major hepatic enzyme system responsible for Phase I metabolism is called the cytochrome P450
enzyme system, which contains many isoenzyme subclasses with varying activity and specificity in Phase I
drug metabolism processes. Cytochrome P450 isoenzymes are grouped into families according to their genetic
similarities.

Phase II Reactions
Once a polar constituent (conjugating agent) is revealed or placed into the molecule, a phase II or conjugation
reaction may occur. This leads to an increase in the polarity of the drug and usually results in the formation of
an inactive compound.
Factors Influencing Conjugation Reaction Pathways
• Limited amount of the conjugate transferase
• Limited ability to synthesize the active nucleotide intermediate
• Limited amount of conjugating agents such as glycine
• N-acetylated conjugation reaction shows genetic polymorphism
• Diminished or defective conjugation reactions e.g. inborn errors

The enzymes involved in the metabolism of drugs may be altered by diet and the coadministration of other
drugs and chemicals.
1. Enzyme induction is a drug - or chemical-stimulated increase in enzyme activity, usually due to an increase
in the amount of enzyme present.
• This will result to faster metabolism
• Alcohol causes auto-induction (stimulates its own metabolism)
• Phenobarbital, phenytoin, and other anticonvulsants are enzyme inducers and can stimulate the
rate of metabolism of another agent (foreign-induction). Other examples are provided in the table below.
2. Enzyme inhibition may be due to substrate competition or due to direct inhibition of drug-metabolizing
enzymes, particularly one of several of the cytochrome P-450 enzymes.
• This will result to a slower rate of metabolism, thus prolonging the pharmacological effects of
the drug whose metabolism is inhibited
• Cimetidine is an example of enzyme inhibitor.

MODULE 6

Anatomy and Physiology of Kidney

The kidney is the main excretory organ for the removal of metabolic waste products and plays a major role in
maintaining the normal fluid volume and electrolyte composition in the body. To maintain salt and water
balance, the kidney excretes excess electrolytes, water, and waste products while con- serving solutes necessary
for proper body function.
In addition, the kidney has two endocrine functions: (1) secretion of renin, which regulates blood pressure, and
(2) secretion of erythropoietin, which stimulates red blood cell production.

Anatomic Considerations
The kidneys are located in the peritoneal cavity. The outer zone of the kidney is called the cortex, and the inner
region is called the medulla.

The nephrons are the basic functional units, collectively responsible for the removal of metabolic waste and the
maintenance of water and electrolyte balance. Each kidney contains 1-1.5 million nephrons. The glomerulus of
each nephron starts in the cortex. Cortical nephrons have short loops of Henle that remain exclusively in the
cortex; juxtamedullary nephrons have long loops of Henle that extend into the medulla. The longer loops of
Henle allow for a greater ability of the nephron to reabsorb water, thereby producing more concentrated urine.

Blood Supply
The kidneys represent about 0.5% of the total body weight and receive approximately 20%-25% of the cardiac
output. The kidney is supplied by blood via the renal artery, which subdivides into the interlobar arteries
penetrating within the kidney and branching further into the afferent arterioles.
Regulation of Renal Blood Flow
Blood flow to an organ is directly proportional to the arteriovenous pressure difference (perfusion pressure)
across the vascular bed and indirectly proportional to the vascular resistance. The normal renal arterial pressure
is approximately 100 mm Hg and falls to approximately 45-60 mm Hg in the glomerulus. This pressure
difference is probably due to the increasing vasculature resistance provided by the small diameters of the
capillary network. The renal blood flow (RBF) is the volume of blood flowing through the renal vasculature per
unit of time. RBF exceeds 1.2 L/min or 1700 L/d.

Glomerular Filtration and Urine Formation

A normal adult subject has a GFR of approximately 120 mL/min. About 180 L of fluid per day are filtered
through the kidneys. In spite of this large filtration volume, the average urine volume is 1-1.5 L. Up to 99% of
the fluid volume filtered at the glomerulus is reabsorbed. Besides fluid regulation, the kidney also regulates the
retention or excretion of various solutes and electrolytes. With the exception of proteins and protein-bound
substances, most small molecules are filtered through the glomerulus from the plasma. The filtrate contains
some ions, glucose, and essential nutrients as well as waste products, such as urea, phosphate, sulfate, and other
substances. The essential nutrients and water are reabsorbed at various sites, including the proximal tubule,
loops of Henle, and distal tubules.

Renal Drug Excretion

Renal excretion is a major route of elimination for many drugs. Drugs that are nonvolatile, are water
soluble, have a low molecular weight (MW), or are slowly biotransformed by the liver are eliminated by renal
excretion. The processes by which a drug is excreted via the kidneys may include any combination of the
following:
1. Glomerular filtration
2. Active tubular secretion
3. Tubular reabsorption

Glomerular Filtration
Glomerular filtration is a unidirectional process that occurs for most small molecules (MW < 500), including
undissociated (nonionized) and dissociated (ionized) drugs. Protein-bound drugs behave as large molecules and
do not get filtered at the glomerulus. The major driving force for glomerular filtration is the hydrostatic
pressure within the glomerular capillaries.
Glomerular filtration rate (GFR) is measured by using a drug that is eliminated primarily by filtration only.
Clinically inulin and creatinine are often used for this purpose, although creatinine is also secreted. GFR is
approximately 125-130 mL/min or about 180-187 L/day.

Active Tubular Secretion

Active tubular secretion is an active transport process. As such, active renal secretion is a carrier-mediated
system that requires energy input, because the drug is transported against a concentration gradient. Drugs may
compete with another for the carrier (e.g., Penicillin-Probenecid).
Drugs commonly used to measure active tubular secretion include p-amino-hippuric acid (PAH) and
iodopyracet (Diodrast). Their clearances (425 to 650 mL/min) reflects the effective renal plasma flow (ERPF).

Tubular Reabsorption
Tubular reabsorption occurs after the drug is filtered through the glomerulus and can be an active or a passive
process involving transporting back into the plasma. The reabsorption of drugs that are acids or weak bases is
influenced by the pH of the fluid in the renal tubule (ie, urine pH) and the pKa of the drug.
• Weak acids in acidic urine = reabsorption
• Weak bases in alkaline urine = reabsorption
Tubular reabsorption is one of the processes by which weak acids and weak bases are excreted via the kidneys.
It is usually influenced by pH of the urine and the pKa of the drug. The percentage of ionized weak acid drug
corresponding to a given pH can be obtained from the Henderson-Hasselbalch equation.

Renal Clearance
Renal clearance, ClR, is defined as the volume that is removed from the drug per unit of time through the
kidney. Similarly, renal clearance may be defined as a constant fraction of the central volume of distribution in
which the drug is contained that is excreted by the kidney per unit of time.

FACTORS AFFECTING RENAL CLEARANCE

• AGE
• SEX - Clearance is approximately 10% lower in females than in males
• DISEASE - Renal clearance is reduced in patients with kidney diseases and cardiac diseases

Creatinine Clearance
As kidney function is lost, the quantity of plasma filtered per minute decreases, with an accompanying decrease
in drug clearance. Thus, creatine clearance is a measure of extent of renal function.

The filtration rate of the kidney can be estimated by a number of methods. One of the most useful, however, is
the estimation of the creatinine clearance rate (CrCl) through the use of the following empiric formulas based
on the patient’s age, weight, and serum creatinine value.
Creatinine is eliminated from the body essentially through renal filtration, reduced kidney performance results
in a reduced creatinine clearance rate. The normal adult value of serum creatinine is 0.7 to 1.5 mg/dL. The
creatinine clearance rate represents the volume of blood plasma that is cleared of creatinine by kidney filtration
per minute. It is expressed in milliliters per minute.

Determining patient-specific creatinine clearance can be accomplished by either direct measurement of the
amount of creatinine contained in a 24-hour urine sample or by estimating this parameter using standard
mathematical equations. Direct measurement is the most accurate of these.

Biliary Excretion
The biliary system of the liver is an important system for the secretion of bile and the excretion of drugs.

While in the liver, drugs or metabolites can also be secreted into the bile in much the same manner as the kidney
secretes drugs into the nephron tubular filtration. Biliary excretion is facilitated by active transport systems
located in the canalicular membrane of the hepatocyte and can be an important hepatic elimination pathway for
many compounds. Since bile is an aqueous solution, it is suitable for dissolving hydrophilic drugs. In addition,
bile acids allow the solubilization of lipid-soluble drugs. Thus, all types of species (anionic, cationic, and
ionized drugs), polar and lipophilic, can be secreted into the bile. These include drug metabolites that have
undergone conjugation with glucuronide during phase II metabolism.

Drugs that are excreted mainly in the bile have molecular weights in excess of 500. Drugs with molecular
weights between 300 and 500 are excreted both in urine and in bile. For these drugs, a decrease in one excretory
route results in a compensatory increase in excretion via the other route. Compounds with molecular weights of
less than 300 are excreted almost exclusively via the kidneys into the urine.

Drugs excreted into the bile include the digitalis glycosides, bile salts, cholesterol, steroids, and indomethacin.
Compounds that enhance bile production stimulate the biliary excretion of drugs normally eliminated by this
route. Furthermore, phenobarbital, which induces many mixed-function oxidase activities, may stimulate the
biliary excretion of drugs by two mechanisms: by an increase in the formation of the glucuronide metabolite
and by an increase in bile flow.

Factors influencing Biliary Excretion

1. Bile production
• Increase bile production increases biliary excretion of drugs
• Food rich in protein increases bile secretion
* Choleresis – formation of bile in the liver
2. Bile flow - Decrease bile flow decreases biliary excretion
* Cholekinesis – emptying of bile from the gall bladder
3. Route of administration
• Drugs given orally may be extracted into the bile to a greater extent than the IV given
medications

Enterohepatic Circulation
A drug or its metabolite is secreted into bile and upon contraction of the gallbladder is excreted into the
duodenum via the common bile duct. Subsequently, the drug or its metabolite may be excreted into the feces or
the drug may be reabsorbed and become systemically available. The cycle in which the drug is absorbed,
excreted into the bile, and reabsorbed is known as enterohepatic circulation. Some drugs excreted as a
glucuronide conjugate become hydrolyzed in the gut back to the parent drug by the action of a β-glucuronidase
enzyme present in the intestinal bacteria. In this case, the parent drug becomes available for reabsorption. The
once-daily dosing of the oral contraceptive pill (containing ethinylestradiol) is attributed to enterohepatic
recirculation.

Significance of Biliary Excretion

When a drug appears in the feces after oral administration, it is difficult to determine whether this presence of
the drug is due to biliary excretion or incomplete absorption. If the drug is given parenterally and then observed
in the feces, one can conclude that some of the drugs was excreted in the bile. Because drug secretion into bile
is an active process, this process can be saturated with high drug concentrations. Moreover, other drugs may
compete for the same carrier system.

In the enterohepatic cycle, a drug secreted in bile is reabsorbed into the circulation from the intestine. Biliary
excretion eliminates substances from the body only to the extent that enterohepatic cycling is incomplete—
when some of the secreted drugs is not reabsorbed from the intestine.

Hepatic Clearance

Hepatic clearance is influenced by hepatic blood flow, drug-protein binding, and intrinsic clearance.
The Intrinsic clearance (Clint)
• The liver’s maximum capacity or the ability to remove a drug in absence of flow limitations
• Directly related to ER (extraction ratio)
• Enzyme inducers increase the elimination of drugs with low Clint
The liver extraction ratio (ER) provides a direct measurement of drug removal from the liver after oral
administration of a drug. The fraction of drugs not reaching systemic circulation is removed through either
protein binding or first-pass effect.
• Drugs of low ER = clearance depends on liver enzyme activity (independent of liver blood flow)
 • Drugs of high ER = clearance depends on liver blood flow (The slower the flow the higher the
extraction, the higher the flow the lower the extraction ratio)
Hepatic clearance may be defined as the volume of blood that perfuses the liver which is cleared of drugs per
unit of time. In most cases, hepatic clearance is estimated as the difference between body clearance and renal
clearance.

ClT = ClR + ClNR

Hepatic drug clearance describes drug metabolism in the liver and accounts for both the effect of blood flow
and the intrinsic ability of the liver to metabolize a drug.

Other pathways for drug excretion may include the excretion of drug into bile, sweat, saliva, milk (via
lactation), or other body fluids. Volatile drugs, such as gaseous anesthetics, alcohol, or drugs with high
volatility, are excreted via the lungs into expired air.

Some drugs are excreted in breast milk, and the excreted drugs are a source of unwanted effects in the nursing
infant. For instance, morphine and other lipid-soluble drugs are excreted in breast milk. While it is best to
avoid all drugs during breastfeeding, there are some breastfeeding women who need to take medications.
Epileptic mothers may have to continue their medication. Some of the older anti-epileptic drugs e.g. diazepam,
are known to get into breast milk and should be avoided during breastfeeding. There is little information about
whether the newer agents get into breast milk, but it is considered that the levels are likely to be too low to have
effects in the newborn.

The mechanisms involved and examples of the other pathways:

1. Salivary excretion
• Passive diffusion of nonionized drug
• Lithium, penicillin, phenytoin are assumed to be actively transported
• This may account for some taste imparted by the drug eliminated via this pathway (e.g. metallic
taste for some minerals, sour taste for acid drugs, etc)
2. Mammary excretion
• Transport is via passive diffusion
• Decreased renal excretion of the nursing mother increases mammary secretion
• Tetracycline excreted into milk may lead to discoloration of teeth
3. Excretion of drugs into sweat
• Follows passive diffusion
• Antipyrine, alcohol, sulfonamides, thiamine, iodine, bromine
4. Excretion of drugs into expired air
• Inverted process of gas uptake
• Excretion of inhaled anesthetics and volatile compounds (e.g., alcohol)
5. Genital excretion
• Into prostate secretion
• Excretion of antineoplastic agents into the seminal fluid
6. Intestinal excretion

MODULE 7
Drug Dosing

Individualization of Drug Dosage Regimens

Not all drugs require rigid individualization of the dosage regimen. Many drugs have a large margin of safety
(ie, exhibit a wide therapeutic window), and strict individualization of the dose is unnecessary. However,
individualization of the dosage regimen is very important for drugs with a narrow therapeutic window (also
known as critical-dose drugs and narrow therapeutic index [NTI] drugs), such as digoxin, aminoglycosides,
antiarrhythmics, anticoagulants, anticonvulsants, and some antiasthmatics, such as theophylline. Critical-dose
drugs are defined as those drugs where comparatively small differences in dose or concentration lead to dose-
and concentration- dependent, serious therapeutic failures and/or serious adverse drug reactions.

Hence, the objective of the dosage regimen design is to produce a safe plasma drug concentration that
does not exceed the minimum toxic concentration or fall below a critical minimum drug concentration
below which the drug is not effective. For this reason, the dose of these drugs is carefully individualized to
avoid plasma drug concentration fluctuations due to intersubject variation in drug absorption, distribution, or
elimination processes.

Therapeutic Drug Monitoring

Therapeutic monitoring of plasma drug concentrations is valuable only if a relationship exists between the
plasma drug concentration and the desired clinical effect or between the plasma drug concentration and
an adverse effect. The therapeutic range for a drug is an approximation of the average plasma drug
concentrations that are safe and efficacious in most patients. The functions of a TDM are listed below:

 Select drug.
 Design dosage regimen.
 Evaluate patient response.
 Determine need for measuring serum drug concentrations.
 Assay for drug concentration in biological fluids.
  Perform pharmacokinetic evaluation of drug concentrations.
 Readjust dosage regimen, if necessary.
 Monitor serum drug concentrations.
 Recommend special requirements.

Loading Dose
As stated previously, after a continuous IV infusion of drug is begun, five drug half-lives are needed to achieve
steady state. In many clinical situations, an immediate effect of a drug is desired in a patient. In these situations,
a loading dose is often administered at the initiation of the infusion to achieve an immediate therapeutic plasma
concentration of the drug. By doing so, a serum concentration within therapeutic range of the drug is maintained
from the outset of therapy. This loading dose is usually relatively large and may produce immediate therapeutic
plasma concentrations.
Note that a loading dose should not be used if substantial side effects occur with large doses of the drug. Also,
sometimes clinicians prefer that drugs accumulate slowly rather than achieve therapeutic concentrations
immediately so that the patient may have adequate time to develop tolerance to the initial side effects (e.g.,
tricyclic antidepressants).

The desired loading dose for many drugs can be derived from the definition of the volume of distribution. As
shown previously, V = X0/C0 for a drug described by a one-compartment model. Rearranging this equation, we
see that the loading dose equals the desired concentration multiplied by the volume of distribution:

Importance of Loading Dose and Maintenance Dose

Since extravascular doses require time for absorption into the plasma to occur, therapeutic effects are delayed
until sufficient plasma concentrations are achieved. To reduce the onset time of the drug—that is, the time it
takes to achieve the minimum effective concentration—a loading (priming) or initial dose of drug is given. The
main objective of the loading dose is to achieve desired plasma concentrations as quickly as possible. If
the drug follows one-compartment pharmacokinetics, then in theory, steady state is also achieved immediately
following the loading dose. Thereafter, a maintenance dose is given to maintain plasma concentration at steady
state so that the therapeutic effect is also maintained. In practice, a loading dose may be given as a bolus dose
or a short-term loading IV infusion.

MODULE 8
Bioequivalence Studies in New Drug Development (NDA)
During drug development, bioequivalence studies are used to compare

 early and late clinical trial formulations;

  formulations used in clinical trials and stability studies, if different;
 clinical trial formulations and to-be-marketed drug products, if different; and
 product strength equivalence, as appropriate.

Purpose of Bioavailability and Bioequivalence Studies

Bioavailability and bioequivalence studies are important in the process of approving pharmaceutical products
for marketing. Bioavailability is defined as the rate and extent to which the active ingredient or active moiety is
absorbed from a drug product and becomes available at the site of action. On the ther hand, Bioequivalence is
defined as the absence of a significant difference in the rate and extent to which the active ingredient or active
moiety becomes available at the site of drug action when administered at the same molar dose under similar
conditions in an appropriately designed study. Bioequivalence studies are used to compare the bioavailability of
the same drug (same salt or ester) from various drug products. Bioavailability and bioequivalence can be
considered as performance measures of the drug product in vivo.

Relative and Absolute Availability

A drug product’s bioavailability provides an estimate of the relative fraction of the administered dose that is
absorbed into the systemic circulation. The AUC is considered the most reliable measure of a drug’s
bioavailability, as it is directly proportional to the total amount of unchanged drug that reaches the systemic
circulation.

Absolute bioavailability compares the bioavailability of the active drug in the systemic circulation following
extravascular administration with the bioavailability of the same drug following intravenous administration.
Intravenous drug administration is considered 100% absorbed.

In a relative bioavailability study, the systemic exposure of a drug in a designated formulation (generally
referred to as treatment A or reference formulation) is compared with that of the same drug administered in a
reference formulation (generally referred to as treatment B or test formulation).
 Used in drug development include studies to characterize food effects and drug–drug interactions.
 Used in developing new formulations of existing immediate-release drug products, such as new
modified-release versions or new fixed-dose combination formulations.
 Used for bridging formulations during drug development
Methods for Assessing Bioavailability and Bioequivalence
The FDA’s regulations list the following approaches to determining bioequivalence, in descending order of
accuracy, sensitivity, and reproducibility:
 In vivo measurement of active moiety or moieties in biological fluid (ie, a pharmacokinetic study)
 In vivo pharmacodynamic (PD) comparison
 In vivo limited clinical comparison
 In vitro comparison
 Any other approach deemed acceptable (by the FDA)

Biopharmaceutic Factors and Rationale for Drug Product Design

In broad terms, the factors affecting drug bioavailability may be related to the formulation of the drug product
or the biological constraints of the patient.

Drugs are not usually given as pure chemical drug substances but are formulated into finished dosage forms (ie,
drug products). These drug products include the active drug substance combined with selected additional
ingredients (excipients) that make up the dosage form. Although excipients are considered inert with respect to
pharmacodynamic activity, excipients are important in the manufacture of the drug product and provide the
functionality to the drug product with respect to drug release and dissolution.

Some common drug products include liquids, tablets, capsules, injectables, suppositories, transdermal
systems, and topical creams and ointments. These finished dosage forms or drug products are then given to
patients to achieve a specific therapeutic objective. The design of the dosage form, the formulation of the drug
product, and the manufacturing process require a thorough understanding of the biopharmaceutic principles of
drug delivery.

Considerations in the design of a drug product to deliver the active drug with the desired bioavailability
characteristics and therapeutic objectives include:
(1) the physicochemical properties of the drug molecule,
(2) the finished dosage form (eg, tablet, capsule, etc),
(3) the nature of the excipients in the drug product,
(4) the method of manufacturing, and
(5) the route of drug administration.

Biopharmaceutics allows for the rational design of drug products and is based on:
 The physical and chemical properties of the drug substance
 The route of drug administration, including the anatomic and physiologic nature of the application site
(eg, oral, topical, injectable, implant, transdermal patch, etc)
 Desired pharmacodynamic effect (eg, immediate or prolonged activity)
 Toxicologic properties of the drug
 Safety of excipients
 Effect of excipients and dosage form on drug product performance
 Manufacturing processes