PHAR H4001: Pharmacology week 9B – CA prep

Jason Gavin PhD, MBA, MPSI

2024-03-19
2024-03-21
Tuesdays 12pm-2pm, Thursdays 4pm-6pm

W/C Week Lecture contents

22/01/2024 week 1 Introduction to pharmacology: drug transport, cell communication, physiology
29/01/2024 week 2 Drug absorption: routes of administration and dosage forms
05/02/2024 week 3 Drug distribution : protein binding, volume of distribution, body compartments
12/02/2024 week 4 Drug metabolism I: biotransformations, phases of metabolism CA 1, P450, metabolism & drug action
19/02/2024 week 5 Drug elimination: clearance, routes of excretion
26/02/2024 week 6 Drug action and pharmacokinetics I: agonists & antagonists, dose-response relationships, signals
04/03/2024 week 7 Drug development: High-throughput screening, pre-clinical % clinical testing, pharmacovigilance
11/03/2024 week 8 Drug action: dosing schedules, delivery systems, case studies
18/03/2024 week 9 Toxicology, CA prep
25/03/2024 - Spring break
01/04/2024 - Spring break
08/04/2024 week 10 Case study 2, CA 2
15/04/2024 week 11 Recap/exam prep
 Review of week 1B - Physiology

The stomach: pH of the GIT: Kidneys

1. Ultrafiltration
2. Tubular reabsorption
3. Tubular secretion
1. Reservoir
2. Mixes juices
3. Churns

Pancreas, gallbladder, SI: Liver: the “bouncer”

1. Digestion
Lungs and skin
1. Secrete enzymes, 2. Storage
hormones, “soap 3. Factory
2. Main site of absorption
3. Coordinated muscle
movements
 Review of week 2A – Oral drug absorption

Definitions: Bioavailability Factors affecting oral absorption

(a) Gastric motility and
splanchnic blood flow
(b) Particle size &
formulation
(c) pH of gastric contents
(d) Area of absorbing surface
available
(e) Gastric secretions &
Rates of drug absorption bacterial metabolism
(f) Metabolism during
absorption & clearance
(g) Direct drug interactions

Fate after absorption: hepatic metabolism & enterohepatic

shunting
 Review of week 2B – Drug absorption II

pH and absorption: pKa and logP: Other routes of admin Ion trapping
Assumptions:
Unionised species
cross membranes.
Ionised species
cannot.
➔ Ion trapping

So at equilibrium:
Remember: • Acidic drugs
concentrate in
A drug generally needs to be UNIONISED to be
absorbed high pH
compartments
Exceptions • Basic drugs
concentrate in
1. Blood flow is dynamic • Features
low pH
compartments
2. Gut motility can vary • Advantages
3. Does not account for surface • Disadvantages
area of SI, active transport etc • Limitations NOT the main determinant of absorption
but will be important for distribution
 Review of week 3A – Drug distribution I

After absorption Plasma protein binding Plasma protein binding

- First pass metabolism (a) Effects on Kinetics (c) Measuring binding
1. Equilibrium dialysis 3. Ultra-filtration
Free drug can: 2. Dynamic dialysis 4. Ultra-centrifugation
• Circulate in blood
• Enter cells/tissue
• Be metabolised
• Be eliminated
- Enterohepatic shunting
(d) Factors affecting binding
(b) Plasma protein types
1. Drug factors
1. Albumin (human serum albumin)
1. Physicochemical
2. Alpha1-acid glycoprotein
2. Affinity
3. Lipoproteins
3. Concentration
4. Globulins
- Bronchial shunting 5. Haemoglobin
2. Interactions
3. Patient factors
Remember: 1. Age
2. Genetics
Affect protein level = affect drug action 3. Disease
 Review of week 3A – Drug distribution II
Body composition & Drug storage & transport Drug storage & transport
compartments Phases of drug transport Special tissue types
We can
analyse 1. Blood brain barrier
distribution by - Less permeable
tracking - Lower drug concentration
plasma
concentration
2. Placenta
Volume of distribution (Vd) Drug storage organs - 6 layers
- Metabolising enzymes
- Foetus vulnerable
1. Adipose tissue
• Sluggish reservoir
• Variable
• Source of toxicity 3. Thyroid
- V. small Vd (<10L): confined to plasma
2. Bones - Iodine special affinity
• Too large to leave (e.g. heparin)
• Binds plasma proteins • Calcium-binding
- Low Vd (10-20L): extracellular only • Source of long-term
- V. high Vd: accumulates in tissues toxicity 4. Red blood cells
• Lipid soluble 3. Liver - Affected by pH and tonicity?
• Low ionisation • Main site of
• Low plasma protein binding accumulation
 Review of week 4A – Drug metabolism I
Where do Biotransformation phase I
biotransformations take
place?

• Intestinal microbes (azo dyes)

• Gastric acid (penicillins) Types of phase I reactions:
• Digestive enzymes (peptides) a) Oxidation
• Enzymes in the intestinal wall a) Hydroxylation
b) Dehydrogenation
c) Carboxylation
d) Deamination
b) Hydrolysis
c) Reduction
 Review of week 4B – Drug metabolism II

Phase 2 metabolism pathways CYP450 mechanism Factors affecting drug

Oxidation requires: metabolism
a) Glucuronidation
• Most common pathway 1. P450 enzyme
b) Sulfation 2. P450-NADPH reductase
• Limited amounts of sulfate 3. NADPH
• More polar metabolites 4. Molecular oxygen
(urinary excretion)
c) Methylation
• Does not increase solubility
• Controls neurotransmitters
• Age (infants vs elderly
Microsomal CYP450 • Genetics & personalised medicine
mono-oxygenases
Impact on drug action
• Mainly in liver/intestines CYP450 interactions
• Vary in sensitivity and specificity 1. Deactivation 5. Altered uptake
• Genetic polymorphisms 2. Activation 6. Altered distribution
• Adds one atom of oxygen to: • Environment/diet 3. Altered 7. Enterohepatic
• Drug as –OH • Inhibitors/inducers 4. No change shunting
• 2 x H+ to form water
 Review of week 5A – Drug excretion I
Half life
Drug half-life (t1/2) is the time required to
reduce the amount of drug in the body by
half during elimination
We generally look at plasma levels as it is
the most conveniently sampled drug
compartment
• Constant in first order kinetics
• Dependent on:
• Vd
• Clearance
Drug dosing measurements
At steady-state after multiple
dosing, the rate of drug
administration is “equivalent”
to the rate of elimination
The therapeutic index (TD50/ED50) is
a numeric measure of the selectivity
of a drug for its desired effect
Clearance
Clearance is “the volume of blood
cleared of drug per unit time. It is:
- Dose independent
- NOT the same as elimination!
- Dependent on blood flow to organ and
plasma protein binding
 Review of week 5B – Drug excretion II

Renal excretion 2. Tubular reabsorption Hepatobiliary excretion

Affected by: PASSIVE diffusion Hydrophilic polar drugs with MW
1. Drug size - Very polar drugs highly >500
2. Water solubility Active transport systems (saturable)
dependent on renal clearance
3. Protein binding
- Depends on diffusion
4. Drug charge/pH (ion trapping in
tubules!) gradient -> liable to
interactions
1. Glomerular filtration
2. Tubular secretion
- Can remove up to 80% drug
- Active symport with Na+
Lipophilic drugs

1. Pulmonary excretion
2. Breastmilk
3. Hair
 Review of week 6A – Drug action I

Drug receptors Partial agonists Non-competitive antagonists

Cellular molecules directly involved in chemical 100% receptors occupied -> cannot
signalling, normally activated by hormones/NTs produce max response and can
Must be selective and specific compete with full agonists
Emax < 100%
D-R relationships: Agonists
Potency is the amount of drug required to Potency (EC50) Efficacy reduced
produce an effect of given intensity unaffected or reduced Emax <100%
Efficacy is the ability of a drug to produce a
response by activating a receptor

Competitive antagonists

Physiological antagonism: Opposes drug

action through completely different
physiological pathways
Chemical antagonism: Binds directly to the
agonist to deactivate it
Potency is reduced Efficacy is unaffected
(EC50 increased) Emax 100%
 Review of week 6B – Drug action II
Signal transduction
Four main receptor types differ by:
1. Location
2. Timescale
3. Second messengers
4. Effectors
Remember:
Ion channels are FASTEST
GPCRs are FAST (and most common)
TKRs and nuclear are LONG TERM
Drug action in the lab Tachyphylaxis & tolerance
Labelling cells: Give drug continuously, effects diminish
1. Radiolabelling Fast -> Desensitisation / tachyphylaxis
2. Immunohistochemistry Over weeks/months -> Tolerance
3. Immunocytochemistry
High affinity and specific
binding
➔ Receptor binding curve
➔ Location of receptors
Organ baths
Organ baths:
Muscle
contractility dose- 1. Change in receptors (tachyphylaxis)
response curves to 2. Loss of receptors (esp CNS drugs)
drugs and electrical 3. Exhaustion of mediators (e.g.
stimulation amphetamine)
4. Increased rate of metabolism (e.g. alcohol)
5. Physiological adaptation (e.g. metformin &
nausea, SSRIs & sedation)
 Review of week 7 – Drug discovery and clinical trials
The pipeline In vivo preclinical research Clinical development
Drug discovery Begins with Investigational New Drug (IND)
Whole animal system tells us more about:
approaches have evolved
• ADME/T, MoA and potential ADRs application to approve clinical trials
from
• Optimal dosages/routes of admin
ethnopharmacology/ Phase Volunteers Aims
• Interactions with diseases/treatments
pharmacognosy to new
• Effectiveness
approaches beginning
with disease mechanisms
I <100 Safety & tolerability, ADME/T, MoA
Choosing an animal model: healthy
Choose the species that most closely mimics the
Preclinical research human pathway of interest! II 100-500
with
Compare to current standard (or
placebo), optimal dosing, potential
Assays are test systems that evaluate the effects of a new • Metabolism, species & strain differences disease risks/ADRs
drug candidate at cellular, molecular and biochemical levels • Spontaneous diseases (want/avoid? tumours?)
• Diet and cost III 1000+ with New drug application,
• Inbred vs outbred strains disease labelling/licensing, prep for production
1. In silico: performed via computer simulation
• Routes of administration (important!)
• Becoming more and more important!
2. In vitro: in a dish outside of a living organism
• Numbers required to show response (cost/time) Post-marketing monitoring (phase IV)
• Duration of study (acute, sub-acute, chronic)
• Provides dynamic, controlled sterile environment
New drug applications include risk management
• Idealised with no “systemic” or PK inputs
• Specific cell lines -> tissue slices/homogenates plans to mitigate any potential risks identified in
• Tox assays: cytostatic/cytotoxity effects, morphology preclinical research/clinical development
and and IC50
3. Ex vivo assay: tissues/cells removed from the body Periodic safety Post-authorisation Urgent safety
• Powerful but expensive – e.g. cancer treatments update safety study referral to/by
reports (PSUR) (PASS) EMA

Aim of these tests: Efficacy/safety info! Aim of these tests: Effectiveness/safety info! Medical device/software combinations: Extra standards
Side effect: Reduced in vivo testing/costs! Side effect: Reduced clinical testing/costs! to adhere to and reporting obligations
 Review of week 8 – Drug dependence/addiction
Dependence
A compulsion to take a substance on a continuous or
periodic basis in order to:
(a) Experience its effects, and/or
(b) Avoid the discomfort of its absence
Stimulants
Amphetamines induce DA and NA release by:
• Competitively inhibiting reuptake transporters,
and in higher doses “reversing” them
• Displacing from storage vesicles
Methylphenidate
Methylphenidate induces DA and NA release by:
• Competitively inhibiting reuptake transporters
• Displacing from storage vesicles

• No displacement from vesicles/”reversing”

Amphetamine tolerance develops rapidly to
Common feature -> drug-induced reward transporters
euphoric effects but more slowly to others
Chemical structure of drugs = “impostors” • Slower absorption
➔ lower abuse potential
Excreted unchanged in urine:
Target:
Hijacked reward system: dopamine
Formulations vary due to Consider:
release in the nucleus accumbens short half life: • Convenience
• Ritalin (2-3h) • Tolerability
Drug, set, setting • Ritalin LA (8-12h) • Comorbidities
• Concerta XL (10-12h) • Diversion potential
• Daytrana (24h patch) • Cost
Drug: The addiction potential of the drug molecule
• Fat soluble v water soluble
• Rapid onset, short acting
Set: The set of conditions in the brain of the individual
• Inter-individual dopaminergic responses - genetics
Setting: The patient’s environment Cocaine & MDMA
• Surrounded by “reminders”
• Ease of access
Confidential

Examples of CA question layouts

CA example: Donepezil and oxybutynin – antagonism

Acetylcholinesterase is an enzyme that breaks down

the neurotransmitter acetylcholinesterase from
synapses.
The Alzheimers’ drug Donepezil acts to inhibit this
enzyme.

(i) What impact would this have on the action of this

neurotransmitter? Increased or decreased? Why?
(ii) ACh acts on a GPCR called muscarinic receptors.
What effect would a muscarinic receptor blocker
have on the action of Donepezil? Is this
competitive or non-competitive?
CA example: Drugs of abuse and dependence potential

Examples of cocaine release. Questions:

What are properties of crack cocaine (freebase) that make it more potentially addictive than
the salt?

Drug properties and addiction potential:

• Fat soluble: more reaches the brain

• Water soluble: easier to inject
• Heat resistant: easier to smoke
• Rapid onset: more potential for abuse
• Short acting: higher risk of withdrawal
CA example: Drug elimination and pH

Acidic/basic urine and drug

excretion rates:
Methamphetamine example:
(i) co-administration with sodium
bicarbonate can reduce rate of
excretion via the kidney – how?
(ii) What impact would this have
on duration of action?

Renal excretion affected by:

1. Drug size
2. Water solubility
3. Protein binding
4. Drug charge/pH (ion trapping in
tubules!)
CA example: Drug toxicity and LD50

Example of animal survival vs

concentration (LC50):
(i) What is LC50 and how does it
differ from LD50?
(ii) Describe how the steepness of
the LD50 slope affects drug
safety?
(iii) What impact does therapeutic
index have on drug dosing?
(iv) What is the difference
between LD50 and NOAEL
Next class

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