Aqueous Penetration of Oral and Topical Indomethacin in Humans

Donald R. Sanders, MD; Bruce Goldstick, MD; Cheryl Kraff, MD; Robert Hutchins, MD; Melvin S. Bernstein; Michael A. Evans, PhD
\s=b\ Aqueous humor and serum indomethacin levels were determined following administration of the drug orally, as a topical 1% aqueous suspension and as a topical 1% oil suspension. Patients receiving indomethacin orally had a mean aqueous humor level below the lower limit of sensitivity of the assay, which is also below the level known to inhibit prostaglandin synthesis in vitro and a mean serum level of 642 ng/mL. Patients receiving the topical 1% aqueous suspension had a mean aqueous level of 198 ng/mL and no detectable serum level. Patients receiving the topical 1% oil suspension had a mean aqueous level of 429 ng/mL, which was significantly higher than that of the aqueous suspension. Both topical suspensions yield levels that are able to inhibit prostaglandin synthesis. Higher aqueous levels with no detectable blood levels (and thus negligible potential for systemic toxic effects) make the topical route of administration preferable to the oral route. (Arch Ophthalmol 1983; 101:1614-

conducted to quantitate aqueous humor and serum indomethacin levels in patients undergoing cataract sur gery who had received topical or oral indomethacin therapy preoperativewas

our knowledge, such an effect has not been demonstrated with indometha cin administered orally. This study

inflammatory activity implies that therapeutic concentrations of indo methacin reach the inflamed tissue; to

ly.

PATIENTS AND METHODS

1616)

has been shown to reduce postopera tive inflammation in patients who have undergone cataract extraction with and without intraocular lens implantation.12 This ocular antipublication Nov 12, 1982. Departments of Ophthalmology (Drs Sanders, Goldstick, Kraff, and Hutchins) and Pharmacology (Drs Sanders and Evans and Mr Bernstein), Abraham Lincoln School of Medicine, University of Illinois at the Medical Center, Chicago. Reprint requests to the Department of Ophthalmology, University of Illinois Eye and Ear Infirmary, 1855 W Taylor St, Chicago, IL 60612 (Dr Sanders).
for
From the

Tropically administered indometha-*- ein in oil or aqueous suspension

Accepted

received indomethacin as a 1% suspension in an aqueous pharmaceutical vehicle administered topically. Two dosage regi mens were used. In the first, five doses of 1 drop each were given at equally spaced intervals during the 24 hours before sur gery; the last drop was given 45 minutes before surgery. In the second regimen, the aqueous suspension was administered as follows: 1 drop every ten to 15 minutes for five doses 18 hours before surgery, 1 drop 12 hours before surgery, 1 drop at bedtime the evening before surgery, then 1 drop at two hours and 90 and 30 minutes before surgery. The results of the two dosage schedules using the aqueous topical prepa ration were combined, since preliminary analysis disclosed no significant difference in aqueous humor indomethacin levels. (3) Patients received indomethacin as a 1% suspension in sesame oil2 in five doses of 1 drop each, as previously described for the topical aqueous suspension. (4) Patients received placebo, the identical pharmaceu tical vehicle as the topical indomethacin aqueous suspension but with no active agent. Patients receiving the topical aque-

All patients were scheduled to undergo cataract surgery and consented to receive one of the following treatment regimens. (1) Patients received 25 mg of oral indo methacin four times during the 24 hours before surgery, with the last dose given two hours preoperatively. (2) Patients

indomethacin suspension or placebo part of a Food and Drug Administra tion-approved randomized prospective study,3 those patients receiving oral indo methacin and topical indomethacin in ses ame oil were recruited after completion of recruitment of the prospective study. Following routine local anesthesia, sur gical preparation, and draping, a partial thickness-3-mm superior limbal incision was made with an ultrasharp disposable razorblade; the anterior chamber was entered with a 25-gauge needle on a tuber culin syringe, and 0.1 to 0.2 mL of aqueous humor was aspirated and immediately fro zen for later indomethacin assay. In a small number of patients receiving oral indomethacin and topical aqueous suspen sion, a 10-mL blood specimen was simulta neously withdrawn from the antecubital fossa and centrifuged at 3,000 rpm for ten minutes. The serum was then separated and immediately frozen until analysis.
ous were

INDOMETHACIN ASSAY

technique, developed in a rapid and sensi tive high-performance liquid chromatography-fluorescence method suit able for small volume (100 /L) sam ples.4 The method consists of deacylation of indomethacin by sodium hydroxide hydrolysis to its fluores cent product, deschlorobenzoylindomethacin, single extraction of an acidbuffered aqueous or serum sample using ethyl acetate, followed by evap oration of the organic phase. The sam ples are reconstituted with 100% methanol and injected into a highperformance liquid Chromatograph. The Chromatographie phase uses a reversed-phase C18-bonded column with a solvent system of 33.3% acetylThe assay
our

laboratory, is

nitride in 0.25% acetic acid. The total

deschlorobenzoylindomethacin (deacylated indomethacin) content in the

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and oil solutions of indomethacin into the anterior chamber of rabbits; the initial concentration in the aqueous humor was greater with the water suspension. In patients, we have found greater penetration with an oil sus pension than with an aqueous phar maceutical vehicle, however, since the dose required to inhibit 50% of enzyme activity (IDS0) for indometha cin in vitro on prostaglandin synthetase is 60 ng/mL,6 both topical regi
mens yield aqueous humor concentra tions that are more than adequate to inhibit prostaglandin synthesis. The aqueous suspension is certainly easier for the patient to use and is more amenable to large scale commercial

topically applied

aqueous

suspensions

Indomethacin Treatment Administered

Aqueous humor indomethacin concentrations in four treatment groups. Dotted lower level of sensitivity of assay procedure. Brackets enclose 1 SEM. Aqueous
Route of Administration and/or Vehicle
Oral indomethacin
No.

line indicates

Humor Indomethacin Concentration

Mean
Concentration'

Signlficancet
SEM Oral

of

Samples
68

(ng/mL)
21

Aqueous
<.01

Oil
<.01

NSt-

49

Topical indomethacin Aqueous suspension Oil suspension

*

19811
8

428

102

sensitivity equals 50 ng/mL. tOne-way analysis of variance with Duncan's multiple range test. tNS indicates not significant at .05 level. Value represents drug concentration two hours after last oral dose. [Value represents drug concentration 30 to 40 minutes after instillation of the last dosage.
Lower limits of

published observation, August 1981). Reported levels of aqueous humor indomethacin after topical adminis tration in rabbits7 are also much high
er

administration of a 1% aqueous sus pension of indomethacin to rabbits yielded 30 to 50 times higher concen trations in the aqueous humor than in the blood. This is in keeping with our high aqueous humor levels in patients (198 ng/mL) and no detectable levels in the blood after topical administra tion. Our aqueous humor levels after top ical administration of indomethacin in humans were 20 times lower than levels obtained when we administered the same preparation to rabbits (un

preparation. Conquet et al7 found that topical

than

those

we

obtained

in

patients.

using fluorometric detection, with excitation at 288 nm and emission at 390 nm (370 nm cutoff filter). An internal stan dard of indole-3-propionic acid is used for quantitation, and the lower limit of sensitivity for indomethacin is 50 ng/mL. Preliminary studies estab lished that no deschlorobenzoylindomethacin was present in the sam ples before alkaline hydrolysis. Fur ther details of the assay method are given elsewhere.4
RESULTS

extract is determined

Aqueous humor indomethacin con centrations in the four groups tested are shown in the Table and Figure. The placebo-treated eyes and those patients who received indomethacin orally had a mean aqueous humor level at or below the lower limit of sensitivity of the assay. There was no significant difference in aqueous lev els of indomethacin between the pla cebo-treated patients and the group

who received indomethacin orally. Serum levels of indomethacin in the patients who received the oral drug were 642 41 ( SEM) ng/mL (N 11). Patients who received the topical 1% aqueous suspension of indomethacin had a mean aqueous humor indomethacin concentration of 198 ng/mL 30 to 40 minutes after the instillation of the last dosage; this concentration was significantly great er than that in the oral-treated and placebo-treated patients (P < .01). No indomethacin was detected in the serum of 19 patients from this group. Patients who received the topical 1% indomethacin suspension in sesame oil had a mean aqueous humor con centration of 428 ng/mL, which was significantly higher than the other
=

Oral administration of indometha cin in rabbits yielded blood levels 90 times higher than levels in the aque ous humor.7 This, again, is compatible with our findings of aqueous humor levels below the limits of sensitivity of our assay and high blood levels (642

ng/mL). Topically administered indometha cin in oil or water suspensions in dosages that decrease postoperative inflammation in patients with cata
high

groups

(P < .01).

COMMENT

Hanna and Sharp,5 using radioactively labeled indomethacin, have demonstrated good penetration of

levels and nondetectable serum levels. No studies have documented the effi cacy of orally administered indometh acin on postoperative inflammation. Such an effect might not be expected, since the mean aqueous level of indo methacin after oral administration is below the ID50 for prostaglandin synthetase inhibition. Cystoid macular edema (CME) is a major complication of modern cata ract surgery. Miyake et al8 have sug gested that prostaglandin synthesis,

ract and intraocular lenses12 produce aqueous humor indomethacin

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into the anterior segment of the eye may reduce the incidence of CME. Topical administration of indometha cin in oil or aqueous medium has been shown to decrease the angiographie incidence of CME in a number of studies1012 without any reported sys-

perhaps by the iris, results in a diffu sion of prostaglandins back to the retina with subsequent development of CME. Analysis of aqueous humor from cataract patients during the postoperative period has disclosed ele vated levels of prostaglandin E and F.9 Interrupting this pathogenic mecha nism with a potent prostaglandin synthetase inhibitor, eg, indomethacin,

temic side effects. The effect of oral indomethacin on the incidence of CME has been equiv ocal.1314 In one study,13 oral adminis tration of indomethacin appeared to be effective in decreasing the inci dence of CME, however, 14% of the patients who received indomethacin therapy stopped the medication spe cifically because of gastrointestinal or CNS side effects; an addition; 1 14% discontinued the medicatioi for unstated reasons. I. a second study,14 oral administration f indomethacin was ineffective in decreasing the inci dence of CME. Our findings combined with the
..

clinical findings described earlier seem to justify the use of the topical route of administration as compared with the oral route. Higher aqueous levels, a better biological response, no detectable blood levels, and, thus, no systemic toxic effects, were noted with topical administration of one fortieth of the oral dose.
This study was supported in part by core grant 1P30EY01792 from the National Eye Institute, National Institutes of Health, Bethesda, Md; by the Veterans Administration Merit Review grant; and by a grant from Merck Sharp & Dohme, West Point, Pa.

References 1. Mochizuki M, Sawa M, Masuda K: Topical indomethacin in intracapsular extraction of senile cataract. Jpn J Ophthalmol 1977;21:215\x=req-\ 226. 2. Sanders DR, Kraff MC, Lieberman HL, et al: Breakdown and reestablishment of the blood\x=req-\ aqueous barrier following implant surgery. Arch
Cedro K, et al: The effect of anti-inflammatory drugs on a cell-free prostaglandin synthesis system from dog spleen: Nature 1972;238:104-106. 7. Conquet PH, Plazonnet J, LeDouarec JC: Arachidonic acid-induced elevation of intraocular pressure and anti-inflammatory agents. Invest Ophthalmol Vis Sci 1975;14:772-775. 8. Miyake K, Sakamura S, Miura H: Prostaglandins as a causative factor of cystoid macular edema after lens extraction. Jpn J Clin Ophthalmol 1978;32:217-222. 9. Miyake K, Sugiyama S, Norimatsu I, et al: Prevention of cystoid macular edema after lens extraction by topical indomethacin: III. Radioimmunoassay measurement of prostaglandins in the aqueous during and after lens extraction procedures. Albrecht Von Graefes Arch Klin Exp 10. Miyake K: Prevention of cystoid macular edema after lens extraction by topical indometh-

acin: II. A control study in bilateral extractions. Jpn J Ophthalmol 1978;22:80-94. 11. Miyake K: Prevention of cystoid macular edema after lens extraction by topical indomethacin: I. A preliminary report. Albrecht Von Graefes Arch Klin Exp Ophthalmol 1977;203:81\x=req-\
88. 12. Yannuzzi LA, Landau AN, Turtz AI: Incidence of aphakic cystoid macular edema with the use of topical indomethacin. Ophthalmology, in
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MS, Evans MA: High-performance liquid chromatography-fluorescence analysis for indomethacin and metabolites in biological fluids. J Chromatogr 1982;229:179-187. 5. Hanna C, Sharp JD: Ocular absorption of indomethacin by the rabbit. Arch Ophthalmol
1972;88:196-198. 6. Flower R, Gryglewski R, Hevberczynska\x=req-\

4. Bernstein

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13. Klein RM, Katzen HM, Yannuzzi LA: The effect of indomethacin pretreatment on aphakic cystoid macular edema. Am J Ophthalmol 1979; 87:487-489. 14. Sholitan DB, Reinhart WJ, Frank KE: Indomethacin as a means of preventing cystoid macular edema following intracapsular cataract extraction. Am Intra Ocular Imp Soc J 1979;
5:137-140.

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