AHSC 2312

Pathology &
Pharmacology
By:
Izzuddin Bin Ahmad Nadzirin
 Pharmacokinetics
 Absorption (A)
 Distribution (D)
 Metabolism (M)
 Excretion (E)
Topics outline
 Biotransformation
 Phase 1
 Phase 2
 Cytochrome P450
 Classification of metabolites produced
 Factors influencing biotransformation
 Excretion
 Organs of excretion
 Kidneys (Renal Excretion)
 Bile (Biliary Excretion)
 Lungs (Pulmonary Excretion)
 Saliva (Salivary Excretion)
 Milk (Mammary Excretion)
 Sweat (Skin Excretion)
BIOTRANSFORMATION
Biotransformation

The elimination of xenobiotics often depends on their

conversion to water-soluble chemicals through
biotransformation.
Biotransformation changes the properties of a xenobiotic:
 lipophilic form (that favors absorption)  hydrophilic form
(favoring excretion in the urine or bile).

The main goal  increase the rate of excretion of

xenobiotics or drugs.
Biotransformation can detoxify or bioactivate xenobiotics
to more toxic forms that can cause tumorigenicity or other
toxicity.
First-pass effect
Inactivates many
drugs

Alternatives:
Parenteral
administration

6
Phases of biotransformation

 There are two phases of biotransformation:

 Phase I reactions: involve oxidation, reduction and hydrolysis,
exposing or introducing a functional group (-OH, -NH2, -SH or –
COOH) to increase reactivity and slightly increase hydrophilicity.
 Phase II reactions: include glucuronidation, sulfation, acetylation,
methylation, conjugation with glutathione, and conjugation with
amino acids (glycine, taurine and glutamic acid) that strongly
increase hydrophilicity.
Phase 1 reactions

 Oxidative reactions
 Catalyzed mostly by enzymes of microsomal fraction (ER) of liver
 Microsomal cytochrome P450 monooxygenase

 Reductive reactions
 Hydrolytic reactions
Phase 1 reactions
 1) Oxidative reactions
 Addition of oxygen or removal of hydrogen.
 Normally the first and most common step involved in the drug
metabolism.
 Majority of oxidation occurs in the liver and it is possible to occur
in intestinal mucosa, lungs and kidney.
 Most important enzyme involved in this type of oxidation is
cytochrome P450.
 Increased polarity of the oxidized products (metabolites) increases
water solubility and reduces their tubular reabsorption, leading to
their excretion in urine.
 These metabolites are more polar than their parent compounds
and might undergo further metabolism by phase II pathways
 2) Reductive reactions
 converse of oxidation (i.e. removal of oxygen or addition of
hydrogen).
 E.g.: Reduction of aldehydes and ketones, reduction of nitro and
azo compounds.
 It is less common than oxidation, but the aim is same to create
polar functional groups that can be eliminated in the urine.
 Cytochrome P450 system is involved in some reaction. Other
reactions are catalyzed by reductase enzymes present in different
sites within the body.
 3) Hydrolytic reactions
 It is the reaction between a compound and water.
 The addition of water across a bond also gives more polar
metabolites.
 Different enzymes catalyze the hydrolysis of drugs:
 i) Esterase enzymes
 Ii) Amidase enzymes
 i) Esterase enzymes
 Usually present in plasma and various tissues, are nonspecific and
catalyze de-esterification.
 Hydrolysis of nonpolar esters into two polar and more water
soluble compounds (i.e. acid and alcohol).
 Esterases are responsible for converting many prodrugs into their
active forms.
 A classical example of ester hydrolysis is the metabolic conversion
of aspirin (acetylsalicylic acid) to salicylic acid and acetic acid.
 ii) Amidase enzymes
 It is the hydrolysis of amides into amine and acid and this is called
Deamination.
 Deamination occurs primarily in the liver.
 Amide drugs are more resistant to hydrolysis (or they are not
hydrolyzed until they reach the liver) than ester drugs which they are
susceptible to plasma esterase.
 The duration of actions of ester drugs are less than the amide
analogues.
 E.g.: Procaine (ester type) injection or topical is usually shorter
acting than its amide analogue procainamide administered similarly.
Cytochrome P450 (CYP)

 The most important enzyme in biotransformation in terms

of the catalytic versatility and number of xenobiotics that
it metabolizes: 57 isozymes and 18 families in human.
 Most CYPs are located in the liver ER (microsomes).
 CYPs are haem-containing proteins
 Microsomal and mitochondrial CYPs play key roles in
biosynthesis or catabolism of steroid hormones, bile acids,
fat-soluble vitamins and fatty acids eicosanoids.
 CYP(family) (subfamily)
(individual gene)
 CYP1A2: metabolizes caffeine
 CYP3A4: most abundant CYP with
broad substrate-specificity
 CYP2E1: metabolizes
acetaminophen and ethanol
 CYPs catalyze several types of
oxidation reactions including:
 Hydroxylation of an aliphatic or
aromatic carbon
 Epoxidation of a double bond
 Heteroatom (S-, N-, and I-) oxygenation
and N-hydroxylation
Oxidation/reduction

 Reductive dehalogenation
 Oxidative dehalogenation
 Cleavage of esters
 Dehydrogenation
 Dealkylation
 Examples of CYP
biotransformation
 Chlorzoxazone: muscle
relaxant—inducer of calcium-
activated potassium channel
 Coumarin: used as an aroma-
enhancer in pipe tobaccos and
certain alcoholic drinks, but has
some hepatotoxic effects
 Mephenytoin—an
anticonvulsant
Classsification of metabolites produced

 1) Inactive metabolites
 2) Metabolites retain similar activity
 3) Metabolites with different activity
 4) Bioactivated metabolites (prodrug technique)
 1) Inactive metabolites: Some metabolites are inactive,
i.e., their pharmacological active parent compound
become inactive.
 E.g.: Hydrolysis of procaine to p-aminobenzoic acid and
diethylethanolamine results in loss of anesthetic activity of
procaine.
 2) Metabolites retain similar activity: Some metabolite
retain the pharmacological activity of their parent
compounds to a greater or lesser degree.
 E.g.: Codeine is demethylated to the more active analgesic
morphine
 3) Metabolites with different activity: Some metabolites
develop activity different from that of their parent drugs.
 E.g.: Iproniazid (antidepressant) is dealkylated to isoniazid
(antitubercular)
 4) Bioactivated metabolites: Some
inactive compounds are converted
to active drugs within the body.
These compounds are called
prodrugs.
 Prodrugs may have advantages over
the active form (active metabolite)
as more stable, having better
bioavailability or less side effects
and toxicity.
 E.g.: Levodopa (antiparkinson disease)
is decarboxylated in the neuron to
active dopamine
Phase 2 reactions

 When phase I reactions are not producing sufficiently

hydrophilic (water soluble) or inactive metabolites to be
eliminated from the body, the drugs or metabolites formed
from phase I reaction undergoes phase II reactions.
 Generally phase I reactions provide a functional group or
handle in the molecules that can undergo phase II
reactions.
 Thus, phase II reactions are those in which the functional
groups of the original drug (or metabolite formed in a
phase I reaction) are masked by a conjugation reaction.
 Phase II conjugation reactions are capable of converting
these metabolites to more polar and water soluble
products.
 Many conjugative enzymes accomplish this objective by
attaching small, polar, and ionizable endogenous molecules
such as glucuronic acid, sulfate, glycine, glutamine and
glutathione to the phase I metabolite or parent drug.
 The resulting conjugated products are very polar (water
soluble), resulting in rapid drug elimination from the body.
 These reactions require both a high-energy molecule and an
enzyme.
 The high-energy molecule consists of a coenzyme which is
bound to the endogenous substrate and the parent drug or
the drug’s metabolite resulted from phase I reaction.
 The enzymes that catalyze conjugation reactions are
called transferases, found mainly in the liver and to a
lesser extent in the intestines and other tissues.
 Most conjugates are biologically inactive and nontoxic
because they are highly polar and unable to cross cell
membrane.
 Exceptions to this are acetylated and methylated
conjugates because these phase II reactions (methylation
and acetylation) do not generally increase water solubility
but serve mainly to terminate or reduce pharmacological
activity (they are usually pharmacologically inactive).
Conjugating molecules

 1- Glucuronic acid conjugation

 It forms O-glucuronides with phenols Ar-OH, alcohols
R-OH, hydroxylamines H2N-OH,and carboxylic acid
RCOOH.
 It can form N-glucuronides with sulfonamides,
amines, amides, and S-glucuronides with thiols.
 2-Sulfate conjugation
 It is less common, restricted to phenols, alcohols,
arylamines, and N-hydroxyl compounds.
 Primary alcohols and aromatic hydroxylamines can
form unstable sulfate conjugates which can be toxic.
 3-Amino acid conjugation
 By the formation of peptide link. With glycine or
glutamine.
 4- Glutathione conjugation
 It reacts with epoxides, alkylhalides, sulfonates,
disulfides, radical species.
 These conjugates are converted to mercapturic
acid and mostly are excreted in bile.
 It is important in detoxifying potentially
dangerous environmental toxins.
 5,6- Methylation and acetylation reactions
 These decrease the polarity of the drugs except
tertiary amines which are converted to polar
quaternary salts.
 The groups susceptible for these reactions are
phenols, amines, and thiols.
 O-methylation of meta-phenolic OH in
catecholamines does not generally increase
water solubility but serve mainly to terminate
or reduce pharmacological activity (they are
usually pharmacologically inactive).
 7- Cholesterol conjugation
 For carboxylic acids by ester link
formation or for drug with ester
group by trans esterification.
 8- Fatty acid conjugation
 For drugs with alcohol functional
groups by ester link.
Extrahepatic metabolism

 Drug biotransformation also occurs in tissues other than

the liver.
 The most common sites include the plasma, GI mucosa,
nasal passages, lungs and kidneys.
 However, metabolism can occur throughout the body.
Factors influencing biotransformation
 1-Chemical Structure
 The chemical structure (the absence or presence of certain functional
groups) of the drug determines its metabolic pathways.
 2-Species differences (Qualitative & Quantitative):
 Qualitative differences may result from a genetic deficiency of a certain
enzyme while quantitative difference may result from a difference in the
enzyme level.
 3-Physiological or disease state
 E.g.: In congestive heart failure, there is decreased hepatic blood flow
due to reduced cardiac output and thus alters the extent of drug
metabolism.
 An alteration in albumin production can alter the fraction of bound to
unbound drug, i.e., a decrease in plasma albumin can increase the
fraction of unbound free drug and vice versa.
 Pathological factors altering liver function can affect hepatic clearance
of the drug.
 4-Genetic variations
 Isoniazid is known to be acetylated by N-acetyltransferase into
inactive metabolite.
 The rate of acetylation in Asian people is higher or faster than that
in Eurpoean or north American people.
 5-Drug dosing
 An increase in drug dosage would increase drug concentration and
may saturate certain metabolic enzymes.
 When metabolic pathway becomes saturated, an alternative
pathway may be pursued.
 6-Nutritional status
 Low protein diet decreases oxidative reactions or conjugation
reactions due to deficiency of certain amino acids such as glycine.
 Vitamin C deficiency can result in a decrease of oxidative pathway
while vitamin E deficiency decreases dealkylation and
hydroxylation.
 Ca, Mg, Zn deficiencies decreases drug metabolism capacity
whereas Fe deficiency increases it.
 Essential fatty acid (esp. Linoleic acid) deficiency reduce the
metabolism of ethyl morphine and hexobarbital by decreasing
certain drug-metabolizing enzymes.
 7-Age
 1- Metabolizing enzymes (sp.glucuronide conjugation)are not fully
developed at birth, so infants and young children need to take
smaller doses than adults to avoid toxic effects.
 2-In elderly, metabolizing enzyme systems decline.
 8-Gender (sex)
 Metabolic differences between females and males have been
observed for certain compounds.
 Metabolism of diazepam, caffeine and paracetamol is faster in
females than in males while oxidative metabolism of lidocaine,
chlordiazepoxide are faster in men than in females.
 9-Drug administration route
 Orally administered drugs are absorbed from the GIT and
transported to the liver before entering the systemic circulation.
Thus the drug is subjected to hepatic metabolism (first pass
effect) before reaching the site of action.
 Sublingually and rectally administered drugs take longer time to
be metabolized than orally taken drugs. Nitroglycerine is
ineffective when taken orally due to hepatic metabolism.
 IV administration avoids first pass effect because the drug is
delivered directly to the blood stream.
 10-Enzyme induction or inhibition
 Several antibiotics are known to inhibit the activity of cytochrome
P450. Phenobarbitone is known to be cytochrome P450 enzyme
inducer while cimetidine is cytochrome P450 inhibitor.
 If warfarin is taken with phenobarbitone, it will be less effective.
While if it is taken with cimetidine, it will be less metabolized and
thus serious side effects may appear.
EXCRETION
Excretion

 A process whereby drugs or metabolites are irreversibly

transferred from internal to external environment through
renal or non renal route.
 Excretion, along with metabolism and tissue
redistribution, is important in determining both the
duration of drug action and the rate of drug elimination.
Organs of excretion

 Kidneys (Renal Excretion)

 Bile (Biliary Excretion)
 Lungs (Pulmonary Excretion)
 Saliva (Salivary Excretion)
 Milk (Mammary Excretion)
 Sweat (Skin Excretion)
Kidney

 Drugs are eliminated from the body primarily by the

kidneys.
 The principal renal mechanisms that are involved in the
excretion of drugs are:
 1) Glomerular filtration
 2) Active tubular secretion
 3) Passive tubular reabsorption
Glomerular filtration

 The ultrastructure of the glomerular capillary wall is such

that it permits a high degree of fluid filtration while
restricting the passage of compounds having relatively
large molecular weights.
 This selective filtration is important in that it prevents
the filtration of plasma proteins (e.g., albumin) that are
important for maintaining an osmotic gradient in the
vasculature and thus plasma volume.
 Several factors, including molecular size, charge, and
shape, influence the glomerular filtration of large
molecules.
 As the ultrafiltrate is formed, any drug that is free in the
plasma water, that is, not bound to plasma proteins or the
formed elements in the blood (e.g., red blood cells), will
be filtered as a result of the driving force provided by
cardiac pumping.
 All unbound drugs will be filtered as long as their
molecular size, charge, and shape are not excessively
large.
 Compounds with 20 Å to 42Å may undergo glomerular
filtration.
Active tubular secretion

 The tubular secretion which is carried out at the level of

the proximal tubule is an active process.
 It is carrier mediated process which requires energy for
transportation of compounds against concentration
gradient. Two secretion mechanisms are identified.
 System for secretion of organic acids/anions
 E.g.: Penicillin, salicylates etc
 System for organic base / cations
 E.g.: Morphine, mecamylamine hexamethonium
Organic Anion Transport Organic Cation Transport

Acetazolamide Acetylcholine

Bile salts Atropine

Hydrochlorothiazide Cimetidine

Furosemide Dopamine

Indomethacin Epinephrine

Penicillin G Morphine

Prostaglandins Neostigmine

Salicylate Quinine
Passive tubular reabsorption

 In the distal tubule there is passive excretion and re-

absorption of drugs.
 Drugs which are present in the glomerular filtrate can be
reabsorbed in the tubules.
 A reason for this is that much of the water, in the filtrate,
has been reabsorbed and therefore the concentration
gradient is now in the direction of reabsorption hence
drug may be readily reabsorbed.
 Many drugs are either weak bases or acids and therefore
the pH of the filtrate can greatly influence the extent of
tubular reabsorption for many drugs.
 When urine is acidic, weak acid drugs tend to be
reabsorbed. Alternatively when urine is more alkaline,
weak bases are more extensively reabsorbed. Making the
urine more acidic can cause less reabsorption of weak
bases or enhanced excretion.
 In the case of a drug overdose it is possible to increase
the excretion of some drugs by suitable adjustment of
urine pH.
 E.g.: In the case of pentobarbital (a weak acid) overdose
it may be possible to increase drug excretion by making
the urine more alkaline with sodium bicarbonate
injection.
Biliary excretion

 Transporters are also present in the canalicular membrane

of the hepatocyte, and these actively secrete drugs and
metabolites into bile.
 E.g.: the organic anion transporting polypeptides (OATPs),
the P-glycoprotein transport system and the multidrug
resistance-associated proteins (MRPs).
 Drug in bile enters the gastrointestinal tract after storage
in the gallbladder. It may then be excreted from the body
by the stool.
 A drug excreted in bile may be reabsorbed from the
gastrointestinal tract or a drug conjugate may be
hydrolyzed by gut bacteria, liberating original drug which
can be returned to the general circulation.
 Such recycling may continue (enterohepatic cycle or
circulation) until the drug either undergoes metabolic
changes in the liver, is excreted by the kidneys, or both.
 Such enterohepatic recycling, if extensive, may prolong
significantly the presence of a drug (or toxin) and its
effects within the body prior to elimination by other
pathways.
 Orally administered activated charcoal and/or anion
exchange resins have been used clinically to interrupt
enterohepatic cycling and trap drugs in the
gastrointestinal tract.
 Cholestatic disease states, in which normal bile flow is
reduced, will influence drug elimination by this route
resulting in increased risk of drug toxicity.
Pulmonary excretion

 Gases and other volatile substances such as general

anesthetics that enter the body primarily through the
respiratory tract can be expected to be excreted by this
route.
 No specialized transport systems are involved in the loss
of substances in expired air; simple diffusion across cell
membranes is predominant.
 The rate of loss of gases is not constant; it depends on the
rate of respiration and pulmonary blood flow.
 The degree of solubility of a gas in blood also will affect
the rate of gas loss.
 Gases such as nitrous oxide, which are not very soluble in
blood, will be excreted rapidly, that is, almost at the rate
at which the blood delivers the drug to the lungs.
 Ethanol, which has a relatively high blood gas solubility, is
excreted very slowly by the lungs.
Salivary excretion

 The pH of saliva varies from 5.8 to 8.4. Unionized lipid

soluble drugs are excreted passively.
 The bitter taste in the mouth of a patient is indication of
drug excreted.
 Some basic drugs inhibit saliva secretion and are
responsible for mouth dryness. Compounds excreted in
saliva are Caffeine, Phenytoin, Theophylline.
Mammary excretion

 Milk consists of lactic secretions which is rich in fats and

proteins.
 Excretion of drug in milk is important as it gains entry in
breast feeding infants.
 pH of milk varies from 6.4 to 7.6. Free unionized and lipid
soluble drugs diffuse passively.
 Highly plasma bound drug like Diazepam is less secreted in
milk.
 Amount of drug excreted in milk is less than 1% and
fraction consumed by infant is too less to produce toxic
effects. Some potent drugs like barbiturates and morphine
may induce toxicity.
Skin excretion

 Drugs excreted through skin via sweat follows pH partition

hypothesis.
 Excretion of drugs through skin may lead to urticaria and
dermatitis. Compounds like benzoic acid, salicylic acid,
alcohol and heavy metals like lead, mercury and arsenic
are excreted in sweat.
Thank you