Binding of drugs to plasma proteins and other tissue components

The same kinds of bonds that are formed when a drug interacts with its
receptor can be formed between drug molecules and other
macromolecular tissue components.

The drug-receptor combination leads directly to a sequence of events

measurable as a biologic effect, whereas binding with a nonreceptor
substance does not.

The binding sites that do not function as true receptors are frequently
referred to as secondary receptors, silent receptors or sites of loss.
The molecules of a drug that are bound to the nonreceptor macromolecule are
neither free to move to a site of action nor free to produce a biologic effect.

The importance of these interactions with sites of loss (silent receptor)

depends on how much drug is bound and on the strength, or riversibility,
of the bond formation.

Binding of drug to tissue constituents can occur

1- at sites of absorption
2- within the plasma
3- at extravascular sites

In the intestine the positively charged quaternary amonium compounds

are strongly bound to highly negatively charged groups of the mucus
secreted into the lumen (binding at sites of absorption)

The proteins of plasma appear to be the most common site for drug binding.
Albumin, the principle protein of plasma, is also the protein with which
the greatest variety of drugs combine.

Antibiotics such as penicillin, tetracycline and streptomycin as well as

drugs like aspirin, the barbiturates and sulfa preparations, among
others, exist in plasma to a greater or lesser extent as a reversibly
bound albumin complex

The tendency to bind with protein-its affinity for protein- is a constant for a
given drug.

The fraction of drug that is

Free drug + Protein Drug-protein complex bound will be in equilibrium
with the fraction of drug that
is free

Protein concentration of plasma fixed

The fraction of drug that is free to leave the plasma is determined only
1- by the concentration of drug
2- strength of the binding

At low concentrations, the stronger the bond between the drug and
protein, the smaller the fraction that is free.

[drug] [free drug]

As drug concentration increases, the concentration of free drug also

gradually rises until all the binding capacity of the protein has been saturated.

At this point, any additional drug will remain unbound.

How does this binding to plasma protein influence the distribution of
a drug to its site of action?

Binding to protein decrease the concentration of free drug in the

circulation lowers the concentration gradient driving the drug out of the
circulation slows its rate of transfer across the capillary.

As the drug leaves the circulation, the protein-drug complex begins to

dissociate and more free drug is available for diffusion.

As long as the binding is reversible, it

does not prevent drug from reaching its
site of action but only retards the rate at
which this occurs.

As drug is eliminated from the body,

more can be dissociated from the
protein complex to replace what is lost.
In this way, plasma protein binding can act as a reservoir to make drug
available over a longer period.

Suramin
Suramin Plasma protein

(a drug used in the

treatment of the protozal
infection trypanosomiasis)

{
It is not distributed to intracellular water
therapeutically effective level It is not altered by chemical reactions
for extended period It is very slowly eliminated
Other tissues of the body can also act as reservoirs for drugs

The sites where drugs accumulate are not those where they exert their
pharmacologic effect.

Tetracycline stored in bone DDT (insecticide) stored in fat

These stored drugs are in equilibrium with the drug in plasma and are returned
to plasma as the plasma concentration decreases upon elimination from the
body.
The rate of release from the storage depots in the case of these two agents is
ordinarily too slow to provide enough circulating drug to produce biologic
effects.

This type of storage represents a site of loss rather than a depot for
continued drug action.

Binding to tissue Chloroquine interact with nucleic acids

component (is used to treat malaria) of the cell nucleus

The drug may achieve a concentration in liver 200 to 700 times the plasma
concentration

Liver site of loss (silent receptor)

Binding of drug to nonreceptor tissue components generally means that

more drug has to be administrated initially in order to ensure its availability to
its site of action.
 Distribution from blood to brain

Capillaries in the brain do not permit substances to leave the blood as readily as
do capillaries elsewhere in the body.

This decreased permeability pertains only to the diffusion of water-soluble or

ionized molecules.

Lipid-soluble substances diffuse across brain capillaries at rates determined by

their lipid/water partition coefficients.

Since the brain receives one-sixth of total

amount of blood leaving the heart, lipid-
soluble drugs are distributed to brain
tissue vary rapidly compared with a
tissue such as muscle.
Water-soluble materials for which active transport processes exist, such as
glucose and amino acids, also gain rapid access to brain cells.

The endothelial cells of brain capillaries appear to be more firmly joined to one
another than is characteristic of other capillary endothelium.

The brain capillaries do not communicate directly with intertitium.

Between the capillaries endothelium and the extracellular space of the brain is
another membrane which is very closely attached to the capillary wall.

This additional membrane is sometimes

referred as the blood-brain barrier.
The vertabrate brain contains a series of hollow compartments, known as
vertricles, that connect to the central canal of the spinal cord.

The canal and the ventricles contain cerebrospinal fluid, which is kept circulating
by the beating of cilia on the epithelial cells that line the ventricles.

Both the brain and the cord are wrapped in three protective membranes, the
meninges: the pia, the fragile arachnoid, tough dura.

The space between the three meninges

are filled with cerebrospinal fluid, which
cushions the nervous tissue against
damage.

The cerebrospinal fluid (CSF) circulates

to the spaces surrounding the surface
of the brain and spinal cord, and from
these spaces the bulk of the fluid flows
directly into the venous drainage
system of the brain.
 Arterial Blood

Blood Brain Barrier Blood-CSF Barrier

Intracellular Extracellular fluid Cerebrospinal Fluid

Brain
Fluid compartment of brain Compartment
CSF
Compartment
Barrier
of Brain Cells

Venous Blood
Distribution from mother to fetus

The exhange between mother and fetus takes place

primarily in the placenta in which connects the
embryo or fetus with the maternal uterine wall.

Within the placenta are relatively large cavities into

which the maternal arterial blood empties and from
which veins arise to carry blood back to the mother.

Fetal capillaries are contained in finger-like processes

villi.

Maternal and fetal blood do not mix, and solute

transfer takes place across the epithelial cells of the
villi and the endothelium of fetal capillaries.

Material reaching the fetal capillaries is carried to

the fetus by the umbilical venous blood.

Material to be transferred from fetus to mother

returns to the villi by the umbilical arterial blood.
The characteristic of drug diffusion from maternal blood to fetal blood are
very similar to those of passage across any epithelial barriers.

Lipid-soluble materials readily move from mother to fetus

Water-soluble drugs move much more slowly
Large molecules move slowly.

The rate and direction of this exchange depends on:

1- the concentration gradients

2- the rate of delivery to the intervillious space and villi

The fastest equilibrium possible between maternal blood and fetal tissues is
about 40 minutes, even when the maternal blood has a constant level of
drug over a period of time.

The rate of maternal blood flow to the placenta limits the availability of drug
to the fetus.
A single administration of a drug may not necessarily lead to pharmacologic
effects in the fetus.

Frequent administration during gestation may produce adverse effects.

Infants born to mothers addicted to drugs like morphine show all the
withdrawal symptoms that addicts show.

The exposure of the pregnant female to certain agents, particularly early

stages of fetal development, has been linked to the production of defects of
one or more of the infant’s organ systems.

}
X-ray irradiation of the pelvic region causes malformed
Viruses offsprings
Many drugs
 How the actions of drugs are terminated
If nothing else happened to a drug after it enters the body, its action
would continue indefinitely.

This would be advantegenous in chronic diseases.

Epilepsy
Diabetes

The interactions between a drug and the body are not confined to the
changes which the drug brings about in living organism; the body also
acts on drugs.

The processes of excretion and biotransformation and to lesser extent,

tissue redistribution terminate the actions of drugs by removing them
from their sites of action.
Excretion is the processes whereby materials are removed from the body to the
external environment.

Biotrasformation is the process by which chemical reactions carried out by the

body convert a drug into a compound different from that originally
administrated.

Tissue redistribution is the removal of a drug from the tissues where it exerts its
effect to tissues unconnected with the characteristic pharmacologic response.

The combined rates at which these processes occur determine the duration
of action of a drug.
 Excretion

On the process of excretion the direction of movement of a drug is just

the opposite of that involved in getting a drug to its site of action.

It is the reverse of distribution and absorption.

Excretion involves movement of a drug from the tissues back into the
circulation and form the bloodstream back into those tissues or organs
separating the internal from the external environment.

Routes through which drugs can leave the body include:

The kidneys
The lungs
The bile
The skin
 The lung is the major organ of excretion for
gaseous substances and agents remaining as
gases in the body are almost completely
eliminated by this route.

Agents that can be volatilized at body

temperature are also excreted in the expired
air to a greater or lesser extent, depending on
their volatility.

General anesthetics
Some alcohol (this is the basis of the
medicolegal test commonly used to determine
whether an individual has ingested alcohol
and to aid in the diagnosis of drunkenness).

Sweat, tears, saliva, nasal excretion and the milk of the lactating mother are
all examples of fluids in which drugs may be excreted.
The amount excreted by any of these routes ordinarily represents only a
minnor fraction of the total amount of drug eliminated from the body.

Drugs that are passed through the bile and into the intestine are usually
reabsorbed into the bloodstream from the intestine.

However, most drugs leave the body in urine.

The major route of drug elimination from the body is renal excretion of drug
metabolites following the hepatic (liver) biodegradation of the drug into drug
metabolites.

These metabolites are more water-soluble, less lipid-soluble, and (usually)

less biologically active (even inactive) when compared with the parent
molecule.

The molecule that was originally injected and

absorbed.
 At the same time that the kidney is performing its excretory function, it must
also carry out its additional functions:

1- to maintain a constant volume of circulating blood and regulate the fluid

content of the body as a whole
2- to regulate the osmatic pressure
3- to adjust the relative and absolute concentrations of normal constituents
of the plasma.

The kidneys, as the “master chemists of the internal environment”, are able to
regulate and maintain the constancy of the volume and composition of the
body’s fluids.

The kidney must be able to obtain readily the substances to be eliminated

from blood and also must be able to return the essential materials that must
be conserved to the blood.
 the long tube connecting the kidney to the
bladder

The arteries leading from the heart to the kidney are short and wide,
permitting a large supply of blood to reach the kidney at a high hydrostatic
pressure.

Between one-fourth and one-fifth of the blood pumped out of the heart at
every beat is routed through the kidney.

A volume of blood equal to the total blood volume of the body is made
available to the kidneys about every four to five minutes.

Nephron, functional unit of
kidney
1 million nephron/kidney
The total length of the tubules of
both kidneys is 75 miles
Upon entering the kidney, the renal artery
branches into smaller and smaller arteries,
and these in turn subdivide into arterioles.
Each Bowman’s capsule is supplied with
one of these arterioles, referred to as the
afferent arteriole.
The network of capilaries- the glomerulus,
formed by subdivision of the afferent
arteriole.
The endothelium of the glomerular capillary
contains large pores which readily permit
passage of all plasma constituents except
macromolecules like proteins.
This filtrate of plasma, lacking only the
plasma proteins, is termed on ultrafiltrate.
The high pressure which forces this fluid out of the glomerular capillaries
also prevents its reentry into capillary bed.

But nearly all this fluid is recaptured by the bloodstream through a second
set of capillaries.

Glomerulus is the first of the two capillary beds between the arterial supply
and venous drainage of the kidney.

The vessel leaving the glomerulus is not a venule but an efferent arteriole.

It subdivided into another network of capillaries nesting around the tubules

of the nephron and forming their blood supply.

It is only after passing through this second capillary bed that blood enters
the venous side of the circulation to be returned to the heart.
Since all the plasma constituents except proteins and protein-bound
compounds pass through the glomerulus, the filtrate contains

Indispensible substances like water, ions, glucose and other

nutrients.

In addition to disposable waste materials such as phosphate,

sulfate and urea, the end-products of protein metabolism.

Glomerular filtration is a physical process dependent for its operation on

energy derived from the work of heart.
The movement of solutes out of the tubular urine, across the tubular
epithelial cells and through the interstitium back into the circulation involves
physicochemical processes.

The driving force for this movement is either a concentration gradient or the
energy derived from the work of the renal tubular cells.
Passive diffusion Active Transport
H2O Glucose
Cl- Amino acids
Urea Some vitamins
Na+
 Renal Excretion of Drugs

As blood flows through the glomerulus , any drug that is free in the
plasma will be filtered together with other plasma constituents.

Only drugs bound to protein or drugs of excessively large molecular size

will be retained in the bloodstream.

Reabsorption of drugs from the glomerular fitrate is governed by the

familiar principles of biotransport.

Removal of water in the normal formation of urine creates concentration

gradients in favor of solute movement out of tubular urine.

Drugs passively diffuse back into the circulation in accordance with their
lipid/water partition coefficients, degree of ionization and molecular size.

The pH of the voided urine may vary from 4.5 to 8.0, depending on the H+
secreted and the quantity of HCO3- reabsorbed.
Normally, the urine is somewhat more acidic than plasma as a result of the
section of H+ into the distal tubule.

This increased acidity of the tubular urine profoundly affects the rate of
reabsorption of weak electrolytes.

The nonionized forms of More lipid-soluble may readily diffuse back

weak electrolytes into the circulation

The ionized or charged forms are trapped in the tubular urine and excreted
 Example:

Undissociated salicylic acid Salicilate ion + H+

0.01% 99.9% 99.9%

at pH 7.4 (in plasma) (water soluble form)

Both the salicylate ion and salicylic acid are filtered across the glomurulus.

As water is removed from the glomerular filtrate, some salicylic acid diffuses
back into the blood.

Acidification of the urine depress the ionization of salicylic acid.

[H+] [Undissociated salicylic acid]

Rate of salicylic acid excretion

Conversely, an alkaline urine promotes the urinary excretion of salicylic
acid.

In fact, practical use is made of these effects of pH on drug excretion in the

treatment of poisoning with certain weak acids, such as phenobarbital.

Sodium bicarbonate may be administered in order to produce an alkaline

urine and hasten elimination of the drug.

For weak bases an alkaline urine retards excretion and an acidic urine
enhances urinary elimination.
 Tubular secretion

The cells of the proximal tubule are capable of secreting several organic
compounds from the blood into the tubular urine.

There are two separate mechanisms for the transport of organic acids, such
as uric acid and the other for organic bases, such as thiomine.

These two secretory systems, unlike the system for H+ secretion, play only
a minor role in the formation of urine in healthy individuals.

The mechanisms responsible for active tubular secretion of organic

compounds are important for the excretion of a number of drugs.

Acids such as penicilin

Phenylbutazone
Bases such as quanine
quaternary ammonium compounds
Uric acid
Since only two transport processes appear to be
responsible for almost all the secretion that does
occur, this may at times place restrictions on the
transport of substances sharing the same system.

Penicilin

When blood coming to the tubule contains more than one of the organic
acids which can be secreted, these compounds will compete with each
other for binding sites on the same carrier.

If the total quantity of acids to be secreted is in excess of available carrier,

the secretion of the individual anions will be decreased compared with their
rates in the absence of each other.
[Uric acid] (in gout) small quantities of penicillin will inhibit the
excretion of the uric acid by competing for the same active secretory
system.

The extent to which the organic acids or bases are eliminated in the urine
following secretion is dependent on their degree of ionization within the
tubular urine.

Penicillin highly ionized in the urine undergo little reabsorption

quaternary ammonium compounds fully ionized regardless of the pH of

the urine

fully eliminated in urine

 Rate of drug excretion
The rate at which a drug will be eliminated in the urine is the net result of the
three renal processes:

Glomerular filtration

Tubular secretion
} depend ondrugtheinconcentration
plasma
of

Tubular reabsorption depends on the concentration of

drug in urine
If we wish to assess the competence of the glomeruli, we need a means of
measuring the volume of plasma that the glomeruli are capable of filtering in a given
period.
The compound would have the following requirements:
1- It must be freely filterable in the glomeruli
2- It must be neither reabsorbed nor actively secreted into tubular urine.
3- It must be nontoxic and have no direct or indirect pharmacologic effect on
renal function
4- It must remain chemically unaltered during its passage through the kidney
5- It must be a chemical that can be accurately determined in both urine and
plasma
Inulin (polymeric carbohydrate) meets all these requirements
Freely filterable by glomeruli
Reach the urine only by glomerular filtration
All inulin is excreted

Following inulin administration, the amount recovered in the urine in a given

interval is equal to the amount filtered by the glomeruli in that same period.

If 10 mg is the amount of inulin recovered in the voided urine in 10 minutes,

then is being filtered in the glomeruli at the rate of 1 mg/minute

How many milliliters of plasma have to be filtered each minute to yield the
amount recovered per minute in the urine?

Take a sample of blood during the time the urine is being collected and
determine how much inulin is present/ml of plasma.

If we find the plasma concentration 0.008 mg/ml

Amount excreted in urine/min = Number of milliliters of plasma filtered per minute
Amount in plasma/ml

1 mg/min inulin in urine =125 ml/min (volume of plasma filtered)

0.008 mg/ml inulin in plasma

Quantitative data on kidney function obtained in this manner are termed a plasma
clearance study.

Plasma clearance is defined as the volume of plasma needed to study the amount
of a specific substance excreted in the urine in 1 minute.

The clearance of a substance such as inulin measured the glomerular filtration

rate (GFR)

In average healthy adult male the GFR (glomerular filtration rate) is about 130
ml/min, indicating that 130 ml of plasma are filtered by the glomeruli/min.
Plasma clearance is usually calculated as follows:

Clearance (ml/min)= UxV

P
U= concentration of test substance/ml of urine
V= is the volume of urine excreted/min
P= is the concentration of test substance/ml of plasma
C= 1mg/ml x 1 ml/min = 125 ml/min
0.008 mg/ml

This equation gives information not only the functional capacity of the
glomeruli but also the kidneys ability to concentrate urine by removal of
water.

124 ml of each 125 ml filtered were absorbed.

Continued excretion at rate of 1ml/min will lead to a daily output of urine of

1440 ml.
Certain organic acids, such as para-aminohippuric acid (PAH) are secreted so
rapidly and efficiency by renal epithelium.

These acids are also not reabsorbed.

The determination of the plasma clearance of any drug can give some insight
into the mechanisms by which the drug is excreted when this clearance is
compared with the normal glomerular filtration rate, ie., 130 ml/min as obtained
for inulin.

Excretion ratio= Plasma clearance of drug (ml/min)

Normal GFR (ml/min)

A ratio less than 1 indicates that the drug is filtered, perhaps also secreted, and
then partially absorbed

Excretion ratio of glucose=0

(since it is completely reabsorbed in the healthy individual)

A value greater than 1 indicates that secretion, in addition to filtration, is involved

in the excretion.

Excretion ratio of PAH=5