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Clinical Pharmacokinetics II
Dr. Kamal Patel
First Year Resident
16/01/2016

Biotransformation
Introduction
Sites of metabolism
First pass metabolism
Pathways of metabolism
Drug transport
Enzymes involved in metabolism
Enzyme induction and inhibition
Factors affecting metabolism

INTRODUCTION
Chemical alteration of drug in body mediated by enzymes
Enzyme catalysed biochemical transformation of xenobiotics within
living organism
Coping mechanism to xenobiotics
Xenobiotics : all chemical substances that are foreign to body and
enter through ingestion, inhalation or dermal exposure
E.g. : drugs, industrial chemicals, pollutants, plant and animal
toxins

Biotransformation plays role in

Termination of drug effect
Protection from toxic metabolite
Bio activation
Carcinogenesis
Toxicity
Conversion of non-polar polar and lipid soluble water soluble

Outcome of biotransformation
1. Pharmacological inactivation occurs in most cases
E.g. Phenobarbitone
Hydroxyphenobarbitone
(active drug)
(inactive metabolite)
2. Bio activation or toxicological activation in case of prodrugs and
procarcinogens
E.g. L-Dopa(inactive)
Dopamine(active)
3. Active metabolite formation from equally active drug
E.g. Amitriptyline
Nortriptyline(active)

Sites of metabolism
Liver Major site
Kidney
Intestine
Lungs
Skin
Adrenal cortex
Placenta

First pass metabolism

Metabolism of drug before reaching systemic circulation
Affects drugs taken by oral and inhalation routes
Decreases bioavailability

Diminished therapeutic response

Insignificant if metabolism produces active metabolites e.g.

propranolol
Highly significant in liver impairment
Can be bypassed by change of route of administration
E.g. lidocaine by i.v. route, isosorbide dinitrate by sublingual
route

First pass metabolism occurring in

Liver Morphine, Pethidine, Xylocaine, Imipramine, Amitriptyline,
Propranolol,

Isosorbide dinitrate, Glyceryl trinitrate

Intestinal Mucosa L-dopa, -methyldopa, Tyramine, Testosterone,

Progesterone,

Chlorpromazine

Bronchial Mucosa Nicotine, Isoprenaline

Pathways of metabolism
Depending reaction type
Phase I reactions Oxidation, Reduction, Hydrolysis
Phase II reactions Conjugation reactions
Depending on enzyme involved
Microsomal
Non-microsomal

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Phase I reactions

Phase II reactions

Degradative/Non-synthetic
reactions
Functionalization reaction

Synthetic reactions

Functional group generated or

Conjugation reaction

exposed
Oxidation, Reduction,
Hydrolysis

Endogenous radical conjugated

to the drug
Conjugation

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Phase I reaction

Phase II reaction

Mainly Microsomal enzymes

Cytochrome P450, Flavin
mono-oxygenase, EH
Metabolite may be active or
inactive

Microsomal, Mitochondrial or
Cytoplasmic enzymes
Transferases
Metabolite is mostly inactive
except
Morphine glucuronide
Sulfate conjugate of Minoxidil

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Phase I reactions
A. Oxidation
1. Microsomal oxidations
Aromatic hydroxylation
Phenytoin
Warfarin
Phenobarbitone
Propranolol

OH

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Aliphatic hydroxylation (side chain hydroxylation)

Pentobarbitone
Digitoxin
R-CH2-CH3
R-CHOH Cyclosporine
CH3
Dealkylation
Mephobarbitone
Phenobarbitone (N-dealkylation)
Amitriptyline
Nortriptyline (N-dealkylation)
Codeine
Morphine (O-dealkylation)
6-Methylthiopurine
Mercaptopurine (S-dealkylation)

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N- Oxidation
Chlorpheniramine
Quinidine
S- Oxidation
Chlorpromazine
Cimetidine
Deamination
Amphetamine

Phenylacetone derivative

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Desulfarization
Parathion to Paraoxon

Epoxide formation
Carbamazepine

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2. Non-microsomal Oxidations
Mitochondrial Oxidations
Catecholamine oxidation by monoamine oxidase
Oxidative deamination
Histamine
Xanthine

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Cytoplasmic Oxidation (dehydrogenation)

Alcohol
Acetaldehyde
Acetic Acid
Pyridoxine
Decarboxylation
Levodopa

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B. Reductions
1. Microsomal reductions
Nitro reduction[R-NO2
R-NH2]
Chloramphenicol to aryl-amine metabolite
Azo reduction [R-N=N-R1
RNH2 + R1NH2 ]
Prontosil (prodrug) to Sulfanilamide and reduction of
Sulfasalazine
Keto reduction [R-(C=O)-R1
R-(CHOH)-R1]
Cortisone, Methadone, Naloxone

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2.

Non-microsomal reduction
Chloral hydrate
Trichloroethanol

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C. Hydrolysis
Mostly non-microsomal except Pethidine, Lidocaine
Breakdown of molecule with help of water molecule
Enzymes esterase, amidase, peptidase, epoxide hydrolase,
phosphatase, protease
Sites liver, intestine, plasma and other tissues
E.g. Procaine, Aspirin, Succinylcholine, Atropine,
Procainamide, Carbamazepine, -lactam ring of penicillin G

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Phase II reactions
A. Glucuronide conjugation
Only microsomal conjugation
Drug or their metabolite with phenolic, carboxylic, amino or
mercapto group
Increases molecular weight
Enzyme UDP-glucuronyl transferase
Conjugate Uridine diphosphate glucuronic acid

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E.g. aspirin, chloramphenicol, diazepam, lorazepam, morphine,

paracetamol
Endogenous substances bilirubin, steroidal hormone, thyroxine
Important role in enterohepatic circulation of drugs and
prolonging drug action
E.g. phenolphthalein, oral contraceptives

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B. N-Acetyl conjugation
Enzyme N- acetyl transferase
Co-factor acetyl coenzyme A
Site cytoplasm of various organs
Substrate aromatic amines and compound with hydrazine
residue
Enzyme controlled by multiple genes genetic polymorphism
E.g. isoniazid, PAS, dapsone, sulphonamide, hydralazine
R-NH2
R-NH-COCH3

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C. Sulfate conjugation
Enzyme Family of sulfotransferase [SULT]
Co-factor 3phosphoadenosine-5-phosphosulfate
Site cytoplasm of various organs
Substrate phenolic, alcoholic and aromatic amine drugs
E.g. chloramphenicol, hydroxyl-coumarins, methyldopa,
adrenal and sex steroids

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D. Amino acid conjugation

Minor pathway
Conjugated with glycine or glutamine
Enzyme Acyl-coenzyme A glycine transferase
Site mitochondria
For drugs with carboxylic acid group
E.g. salicylates, benzoic acid, nicotinic acid, deoxycholic acid

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E. Methyl conjugation
Minor pathway
Enzyme transmethylase/ methyl transferase
Cofactor S adenosine methionine
Substrate amines and phenols
E.g. catecholamines, histamine, methyldopa, captopril

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F. Glutathione conjugation (cytosol)

Minor pathway
Enzyme glutathione s-transferase
Substrate epoxides, NO2 group containing drugs and
hydroxylamines
E.g. ethacrynic acid, sulfobromophthalein
Important in inactivation of highly reactive quinone or epoxide
metabolite formed during metabolism of some drugs like
paracetamol

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G. Ribonucleoside and Ribonucleotide synthesis

Minor pathway
Purine and pyrimidine antimetabolites form their active
metabolite by forming ribonucleosides and ribonucleotides

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Active drug transport

Oral bioavailability

Hepatic metabolism

Renal clearance

Transport into enterocyte

Active excretion into intestinal lumen
Transport into hepatocyte
Excretion in bile
Transport into proximal tubular cells
Excretion into tubular lumen

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Oral bioavailability
MDR-1 or P-glycoprotein efflux transporter
E.g. digoxin, HIV-1 protease inhibitors
Drug metabolism from portal circulation
OATP (organic anion transporting peptide) and OCT (organic
cation transporter)
Relevant for HMG Co-A reductase inhibitors (statins)
E.g. pravastatin metabolism
OATP1B1 transports into
hepatocyte
prevents rhabdomyolysis prevents uptake by muscles

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Renal clearance
Organic anion transporter renal secretion of anionic drugs
E.g. lactam antibiotics, NSAIDs, antiviral nucleoside analogues

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Enzymes
Microsomal enzymes
Location smooth endoplasmic reticulum
Organs liver, kidney, intestinal mucosa, lungs
Nonspecific in action metabolism of only lipid soluble drugs
Can be induced or inhibited
Catalyse most of phase I reactions and phase II glucuronyl
conjugation
E.g. Cytochrome P450, Mono oxygenases, UGT, Epoxide
hydrolases

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Cytochrome P 450
Enzyme superfamily with heme molecule bound to polypeptide
chain
Require molecular O2 and H+ from NADPH
Specific for endogenous substrate
Non specific for xenobiotics metabolism
Classified on basis of amino acid sequence and cDNA cloning form
E.g. - CYP1(family)A(subfamily)1(isoenzyme)
P pink and 450 light wavelength absorption peak

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CYP450 reduced form with CO forms pink compound with

absorption peak at 450nm
CYPs involved in Xenobiotic metabolism CYP1, CYP2, CYP3
CYP3A > CYP2D > CYP2C > CYP2E
Exhibit genetic polymorphism

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CYP3A4 & CYP3A5

Drugs
Nearly 50%
Cyclosporine,
Substrate Erythromycin, Atorvastatin,
s
Ritonavir, Midazolam,
Sildenafil
Barbiturates, Phenytoin,
Rifampicin,
Inducers
Carbamazepine, St.Johns
wort
Macrolides, Antifungal,
Inhibitors Ritonavir, Verapamil,
Diltiazem
CYP3A4>CYP3A5

CYP2D6
25 30%
TCAs, SSRIs, Neuroleptics,
Codeine, Flecainide, blockers

Unknown

Quinidine, Fluoxetine,
Amiodarone, Haloperidol
Genetic polymorphism

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CYP2C8 & CYP2C9

CYP2C19

Drugs

15 18 (10%)

12 15

Substrates

Phenytoin, Warfarin,
Carbamazepine, Losartan,
Ibuprofen

Inducers

Barbiturates, Rifampicin

Inhibitors

Fluconazole, Amiodarone

Clomipramine,
Omeprazole, Clopidogrel,
Propranolol, Diazepam
Rifampin, Prednisone,
Carbamazepine
Omeprazole, Fluoxetine,
Ritonavir

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CYP1A1 & CYP1A2

Substrates

Inducers

Inhibitors

Theophylline, Caffeine,
Paracetamol,
Carbamazepine
Barbiturates, Rifampicin,
Carbamazepine, Cigarette
smoke, Polycyclic
hydrocarbons, Charcoal
broiled meat
Quinolones, Fluvoxamine
Activation of procarcinogen

CYP2E1
Alcohol, Halothane,
Enflurane, Paracetamol

Chronic alcoholism,
Isoniazid
Disulfiram

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Flavin Monooxygenase
Catalyse oxidation at N, P or S atom
6 families FMO3 imp for metabolism
Distinct from cytochrome P450
Substrates Cimetidine, Ranitidine, Clozapine, Itopride
Genetic deficiency Fish odour syndrome [TMAO TMA]
Itopride vs Cisapride imp for new drug development

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Epoxide hydrolase
2 types- soluble and microsomal
Inactivates highly reactive electrophile produced by CYPs
E.g. carbamazepine
Inhibition active metabolite
side effects

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Non microsomal enzymes

Present in cytoplasm, mitochondria, plasma
Mono-amine oxidase, Esterase, Amidase, Transferases, Conjugases
Catalyses phase II reactions mostly, some oxidation, reduction and
hydrolysis
Usually non inducible but can be inhibited
Genetic variation
Pseudocholinesterase, Acetyl transferase

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Non enzymatic biotransformation

Hoffman elimination
Atracurium and Cis-atracurium
Metabolism by molecular rearrangement without enzyme
involvement

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Enzyme induction
Xenobiotics bind
to nuclear
receptors [PXR,
CAR, AhR]

Xenobiotic
nuclear receptor
activation

Complex
translocated to
nucleus

Increased
expression of
enzymes
[CYP450, UGTs]

Increased
transcription

Complex binds
to promoter site

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Consequences
intensity / duration of action e.g. OCP
intensity / duration of action e.g. PCM toxicity
Tolerance (autoinduction) e.g. Carbamazepine, Rifampin
Precipitate acute intermittent porphyria
Therapeutic Uses
Congenital non haemolytic anaemia - Phenobarbitone
Cushing syndrome Phenytoin
Chronic poisoning

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Enzyme inhibition
Competitive inhibition e.g. ketoconazole
Irreversible inhibition e.g. secobarbital
Fast process compared to induction
plasma concentration of drug Drug toxicities
Therapeutic use
Ritonavir in sub-therapeutic doses with Lopinavir
Drug transporters induced or inhibited
Macrolides inhibit MDR1 increased serum Digoxin level

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Factors affecting metabolism

Age and Gender
Children low activity of UDPGT Gray baby syndrome
(chloramphenicol), neonatal jaundice
Elderly - hepatic blood flow and enzyme activity
metabolism (propranolol, pethidine)

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Race and ethnicity

Chinese high alcohol dehydrogenase and low aldehyde
dehydrogenase
Caucasians 8% has functionally inactive CYP2D6 (TCAs, blockers, Codeine)
Warfarin - sensitivity in Asian-American, sensitivity in
African-american
Diet and Environment
Alter drug metabolism by induction or inhibition of enzyme
Grape fruit juice inhibit CYP3A4

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Diseases
Mainly liver pathologies and thyroid dysfunction
Drug-Drug interactions
Due to enzyme induction or inhibition

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Genetic
Atypical pseudocholinesterase autosomal recessive trait
N-acetyl transferase genetic polymorphism
Codeine CYP2D6 polymorphism

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References
Frank JG, Michael C, Robert HT. Drug Metabolism. In: Brunton LL,
editor. Goodman & Gilmans The Pharmacological Basis of
Therapeutics. 12th edition. New York: Mc Graw Hill
Publication;2011.p.123-144.
Taniguchi C, Guengerich FP. Drug Metabolism. In: Golan DE, editor.
Principles of Pharmacology the pathophysiologic basis of drug
therapy. 3rd edition. New Delhi: Wolters Kluwer; 2012. p. 43-55.
Sharma HL, Sharma KK. Principles of Pharmacology. 2nd Edition.
Hyderabad:Paras Medical Publisher, Hyderabad, 2011. p.25-55.