GENERALPHARMACO-

KINETICSAssoc. Prof. I. LambevE-mail: itlambev@mail.bg

Pharmacokinetics– how does the human bodyact on the drugs?

Pharmacokinetics is the quantitative study of drug movement in, through and out of the body.Intensity of effect is related to the concentration of the drug at the site of action, which dependson its pharmacokinetic properties.

Pharmacokinetic properties of the drug determine the route(s) of administration, dose, latency of onset, time of peak action, durationof action and frequency of drug administration.

All pharmacokinetics processes involve transportof the drug across biological lipid membrane.

Passive diffusionthrough lipid

Filtration Carrier transport

Passive transport- Passive diffusion- Filtration

Specialized transport- Carrier transport

Active transport Facilitated diffusion

- Pinocytosis, etc.

Passive (simple) diffusionThe lipid soluble unionized drug diffuse across the lipid biomembrane in the direction of its concentration gradient. It does not need energy.Most drugs are weak electrolytes. Their ionizationis pH dependent. The ionization of a weak acid (AH)is given by the equation of Henderson–Hasselbalch:

pKa = pH + log10 ------[AH][A–]

pKa is the negative logarithm of acidic dissociationconstant of the weak electrolyte. If the concentrationof unionized drug [AH] is equal to concentration ofionized drug [A–], then [AH] --------- = 1 [A–]since log 1 is 0, under this condition pH = pKa.In this case the molecules of drugs are 50% unionized.

pKb = pH + log10 ------For a weak base:

[BH+]

[B]

FiltrationFiltration is passage of a drug through aqueous poresof the membrane, localized in paracellular spaces.The moving force is hydrostatic or osmotic pressure. Lipid insoluble drugs cross the biomembrane byfiltration only if their molecular size is smaller than the diameter of the enlarged aqueous pores. The filtration has an importance mainly at the levelof renal glomerulus, where the size of capillaries havelarge pores (40 Å) and most drugs (even albumin)can filtrate. The brain capillary pores have small size.

Carrier transport – by combination with a carrier molecule which acts asa ferry-boat across the lipid region of the membrane.Carrier transport is saturable and competitively inhibited by analogues which utilize the same carrier.

a) Active transport is a movement against theconcentration gradient. It needs energy and isinhibited by metabolic poisons. Levodopa andmethyldopa are actively absorbed from the gutby aromatic amino acid transport.

b) Facilitated diffusion. This proceeds more rapidlythan passive (simple) diffusion and translocateseven nondiffusible substrates, but along their concentration gradient, therefore, does notneed energy. Example: Facilitated transport of glucose.

Pinocytosis involves the invagination of a partof the cell membrane and trapping within the cellof a small vesicle containing extracellular consti-tuents. The vesicle contents can than be releasedwithin the cell, or extruded from the other side ofthe cell. Pinocytosis is important for the transportof some macromolecules (e.g. insulin through BBB).

I. ABSORPTIONI. ABSORPTION

It is the passage of drug from the site of administration into the circulation.

Aqueous solubility. Drugs given in solid form mustdissolve in the aqueous biophase before they areabsorbed. For poorly water soluble drugs (aspirin, griseofulvin) the rate of dissolution governs the rateof absorption. If a drug is given as water solution, it is absorbed faster than the same given in solidform or as a oily solution.

Concentration. Passive transport depends on theconcentration gradient. A drug given as concentratedsolution is absorbed faster than dilute solution.

Area of absorbing surface. If the area is larger, the absorption is faster.

Vascularity of absorbing surface. Blood circu-lation removes the drug from the site of absorption and maintains concentration gradient across themembrane. Increased blood flow hastensdrug absorption.

Route of administration affects drug absorption, because each route has itsown peculiarities.

Oral application. Unionized lipid soluble drugs (e.g.ethanol) are readily absorbed from GIT. Acid drugs (aspi-rin, barbiturates, etc.) are predominantly unionized in theacid gastric juice and are absorbed from the stomach. Aciddrugs absorption from the stomach is slower, because themucosa is thick, covered with mucus and the surface is small.Basic drugs (e.g. atropine, morphine, etc.) are largely ioni-zed and are absorbed only from the duodenum.

Presence of food dilutes the drug and retards absorption.

Certain drugs form poorly absorbed complexes with food constituents, e.g. tetracyclines with calcium present in milk.Food delays gastric emptying.Most drugs are absorbedbetter if taken on an empty stomach. Highly ionized drugs, e.g. amikacin, gentamicin, neostigmine, are poorly absorbed when given orally.

Certain drugs are degraded in the GIT, e.g. penicillin Gby acid, insulin by peptidases, and are ineffective orally.Enteric coated tablets (having acid resistant coating) andsustained released preparations can be used to overcomeacid ability, gastric irritancy and brief duration of action.

Intestinal absorption:- duodenum (B1, Fe2+)- ileum (B12, A, D, E, K)- large intestine (water, Na+, Cl-, K+)

Drugs can also alter absorption by gut wall effect: altering motility (atropine, amitriptyline, pethidine, methoclopramide) or causing mucosal damage (neomycin, methotrexate, reserpine, vinblastine).

Alteration of gut flora by antibiotics may disrupt theenterohepatic recirculation of oral contraceptives and digoxin.

S.c. and i.m. applicationBy these routes the drug is deposited in the vicinity ofthe capillaries. Lipid soluble drugs pass readily acrossthe whole surface of the capillary endothelium, butvery large molecules are absorbed through lymphatics.

Many drugs not absorbed orally are absorbed parenterally.Absorption from s.c. site is slower than that from i.m. site,but both are generally faster and more predictable than p.o. absorption. Application of heat and muscular exerciseaccelerate drug absorption by increasing blood flow.Application of vasoconstrictors (e.g. adrenaline) retardabsorption. Many depot preparations (preparations with along action), such as benzatine benzylpenicillin and protamine zinc insulin can be given by these routes.

Topical applications(skin, cornea, mucous membranes)Systemic absorption depends on lipid solubility. Only a few drugs significantly penetrate intact skin.

Nitroglycerine, hyoscine (scopolamine) and estradiolhave been used in this manner. Glucocorticosteroids(GCS) applied over extensive areas can produce systemic effects and pituitary-adrenal suppression.

Cornea is permeable to lipid soluble, unionized physo-stigmine but not to highly ionized neostigmine.

Similarly, the mucous membrane of the mouth,rectum and vagina absorb lipophilic drugs, e.g. estrogen cream applied intravaginally has producedgynecomastia in the male partner.

II. DISTRIBUTIONII. DISTRIBUTION

It is the passage of a drug from the circulation to the tissue and the site of its action.

The extent of distribution of a drug depends on its lipidsolubility, ionization at physiological pH (dependent on pK), extent of binding to plasma and tissue proteins,and differences in regional blood flow, disease like CHF, uremia, cirrhosis. Movement of a drug proceeds until an equilibration isestablished between unbound drug in plasma andtissue fluids.

Body fluid compartments

The total body water as a percentage of bodymass varies from 50% to 70%, being ratherless in women than in man. Body water is distributed into the following main compartments:

1. plasma (5% of body mass)2. intestinal fluid (16%)3. intracellular fluid (35%)4. transcellular fluid (2%)5. fat (20%)

Two-compartment pharmacokinetic model

Apparent volume of distribution (Vd)It is accept that the body behaves as a singlehomogeneous compartment with volume (Vd) in which the drug gets immediately distributed:

Vd = -----------------------------Dose administered

Plasma concentration

Drugs extensively bound to plasma proteins are largelyrestricted to the vascular compartment and have low Vd(e.g. warfarin – 99% bound and its Vd is 0,1 L/kg).

Drugs sequestrated in other tissues may have Vd muchmore than the total body water or even body mass, e.g. digoxin (6 L/kg) and propranolol (3 to 4 L/kg) because most of the drug is present in other tissues, and theplasma concentration is low.

Therefore, in case of poisoning, drugs with largeVd are not easily removed by haemodialysis.

Redistribution. Highly lipid soluble drugs given i.v. or by inhalation get distributed to organs with highblood flow (brain, heart, kidney, liver). Later they getdistributed to less vascular tissues (muscles and fat)and the drug-plasma concentrations falls.

The greater lipid solubility of the drug hastens its redistribution. Anaesthetic action of thiopentone(thiopental) is terminated in few minutes due toredistribution. However, when the same drug is givenrepeatedly or continuously over long periods the lowperfusion high capacity sites get progressively filledup and the drug becomes longer acting.

Thiopental(thiopentone)-redistri- bution in muscle and fat (long post- narcotic sleep)

Bioavailability refers to the rate and extent of absorption of a drug from dosage form as determinedby its concentration-time curve in blood or by its excretionin urine. It is a measure of the fraction (F) of administereddose of a drug that reaches the systemic circulation in theunchanged form. Bioavailability of a drug injected i.v. is 100%, but is

frequently lower after oral ingestion, because:a) The drug may incompetely absorbb) The absorbed drug may undergo first pass metabolism in intestinal wall and/or liver, or be excreted in bile.

Time (h)10 1550

(i.v. application)

(p.o. application)

Plas

ma

conc

entra

tion

(mcg

/ml)

AUC p.o.F = ------------ x 100% AUC i.v.

AUC – area under the curveF – bioavailability

Blood brain barrier (BBB): includes the capillary en-dothelial cells (which have tight junctions and lack largeintracellular pores) and an investment of glial tissue,over the capillaries. A similar barrier is loctated inthe choroid plexus.

BBB is lipid and limits the entry of non-lipid solubledrugs (amikacin, gentamicin, neostigmine etc.).Only lipid soluble unionized drugs penetrate and have action on the CNS.

Efflux carriers like P-gp (glycoprotein) present in braincapillary endothelial cells (also in intestinal mucosal,renal tubular, hepatic canicular, placental, and testicularcells) extrude drugs that enter the brain by other processes.

Inflammation of the meninges of the brain increases permeability of the BBB.

Dopamine (DA) does not enter the brain, but its precursorlevodopa does. This is used later in parkinsonism.

L-DOPA(Levodopa)

70% 27–29%

1–3%

DDC

МАО

DDC

COMT

Brain

DDC – DOPA-decarboxilase; COMT – catechol-О-methyltransferase

GITBlood andperipheral tissues

Placental barrier. Placental membranes are lipidand allow free passage of lipophilic drug, while restricting hydrophilic drugs. The placental P-gp also serves tolimit foetal exposure to maternally administered drugs.However restricted amounts of nonlipid soluble drugs, when present in high concentration or for long periodsin maternal circulation, gain access to the foetus. Thus, itis an incomplete barrier and many drugs, taken by themother, can affect the foetus or the newborn.Penicillins, azithromycin, and erythromycin do not affectthe foetus and can be used during the pregnancy.

Plasma protein binding (PPB). Most drugs possess physicochemical affinity for plasma proteins. Acidicdrugs bind to plasma albumin and basic drugsto α1-glycoprotein. Extent of binding depends on the in-dividual compound. Increasing the concentration of a drugcan progressively saturate the binding sites. The clinicalsignificant implications of PPB are:

a) Highly PPB drugs are largely restricted to the vascular compartment and tend to have lower Vd.b) The PPB fraction is not available for action.c) There is an equilibration between the PPB fraction of the drug and the free molecules of the drug.

d) The drugs with high physicochemical affinity for plasma proteins (e.g. aspirin, sulfonamides, chloramphenicol) can replace the other drugs (e.g. acenocoumarol, warfarin) or endogenous compounds (bilirubin) with lower affinity.e) High degree of protein binding makes the drug long- acting, because bound fraction is not available for metabolism, unless it is actively excreted by the liver or kidney tubules.f) Generally expressed plasma concentrations of the drug refer to bound as well as free drug.g) In hypoalbuminemia, binding may be reduced and high concentration of free drug may be attained (e.g. phenytoin).

Tissue storage. Drugs may also accumulate in specificorgans or get bound to specific tissue constituents, e.g.:Heart and skeletal muscles – digoxin (to muscle proteins)Liver – chloroquine, tetracyclines, digoxinKidney – digoxin, chloroquineThyroid gland – iodineBrain – chlorpromazine, isoniazid, acetazolamideRetina – chloroquine (to nucleoproteins)Iris – ephedrine, atropine (to melanin)Bones and teeth – tetracyclines, heavy metals (to mucopolysaccharide of connective tissue)Adipose tissues – thiopental, ether, minocycline, DDT

III. METABOLISM (BIOTRANSFORMATION)III. METABOLISM (BIOTRANSFORMATION)

Metabolism includes chemical alteration of the drugs inthe body. Most hydrophilic drugs (amikacin, gentamycin,neostigmine, mannitol) are not biotransformated and areexcreted unchanged. The mechanism to metabolize drugsis developed to protect the body from toxins. The primarysite for drug metabolism is the liver, other sites are the kidney, intestine, lungs, and plasma.Metabolism of drugs may lead to the following: a) Inactivation. Most drugs and their active metabolitesare converted to less active or inactive metabolites, e.g.phenobarbital, morphine, propranolol, etc.

b) Active metabolite from an active drug. Many drugsare converted to one or more active metabolites (e.g.diazepam, amitriptyline).

c) Activation of inactive drug. Few drugs (so called prodrugs) are inactive as such. They need conversionin the body to one or more active metabolites (e.g. levodopa, benfothiamine, enalapril, perindopril). The prodrug may offer advantages: their active formsmay be more stable; they can have better bioavailability (e.g. benfothiamine), or other desirable pharmacokinetic properties or less side effects and toxicity.

Biotransformation reactions can be classified into twophases: I (no synthetic) and II (synthetic, conjugation).

Phase I (no synthetic reactions)

a) Oxidation is the most important drug metabolizingreaction. Various oxidation reactions are hydroxylation;oxygenation at C-, N- or S-atoms; N or 0-dealkylation,oxidative deamination, etc. Oxidative reactions are mostly carried out by a group of monooxygenases in the liver, which in the final step involve cytochrome P450 reductase and O2. There are more than 200 cytochrome P450 isoenzymes, differing in their affinity for various substances (drugs). They are grouped into > 20 families.

CYP 3A4/5 carry out biotransforma-tion of the largest number (≈ 50%) ofdrugs. In addition to the liver, these isoformsare expressed in the intestine (responsible for first pass metabolism at this site) and the kidney too. Inhibition ofCYP 3A4 by erythromycin, clarithromycin, ketoconzole,itraconazole, verapamil, diltiazem, and a constituent of grape fruit juice are responsible for unwanted interactionwith terfenadine. Rifampicin, phenytoin, carbmazepine,phenobarbital are inducers of the CYP 3A4.

KetoconazoleGestodene

MidazolamNifedipineErythromycinCyclosporine

TolbutamideWarfarinPhenytoin

MephenytoinOmeprazole

CaffeineTheophyllineTacrine

CumarinsChlor-zoxazone

Substrates:

Inhibitors:

Methoxsalen Fluconazole Sulphaphenazole FurafyllineFluvoxamine

QuinidineTetrahydro-furane

Pheno-barbital

PhenobarbitalRifampicin

PhenobarbitalRifampicin

PhenobarbitalRifampicinDexamethasoneCarbamazepine

OmeprazoleNicotine

EthanolIsoniazid

CYP2C8/9/18~20%

CYP1A2~15%CYP2C19

<5%CYP2A6

<5%

CYP2D6<5%

CYP2E1~10%

CYP2B6 CYP1A1CYP3A4/5(30–50%)

Inducers:

Dextro-metorphanDebrisoquine

Barbiturates, phenothiazines, paracetamol, streroids,phenytoin, benzodiazepines, theophyllin and many otherdrugs are oxidized by CYP450. Some other drugs (adrenaline, mercaptopurine) and ethanol are oxidizedby mitochondrial or cytoplasmic enzymes.

b) Reduction. This reaction is conversed of oxidation and involves CYP450 enzymes working in the opposite direction. Drugs, primarily reduced, are chloramphenicol, levodopa, halothane.

Levodopa (DOPA) DopamineDOPA-decarboxylase

Ester + H20 Acid + AlcoholEsterase

Similarly amides and polypeptides are hydrolyzed by amidase and peptidases. Hydrolysis occurs in the liver,intestines, plasma, and other tissues. Examples arecholine esters, procaine, lidocaine, pethidine, oxytocin.d) Cyclization is formation of a ring structure from a straight chain compound, e.g. proguanil.

e) Decyclization is opening up of a ring structure of the cyclic molecule, e.g. phenytoin, barbiturates.

c) Hydrolysis. This is cleavage of a drug molecule by taking up a molecule of water.

Phase II – synthetic (conjugation) reactions

These involve conjugation of the drug or its phase I meta-bolite with an endogenous substrate to form a polar highlyionized organic acid, which is easily excreted in urine orbile. Conjugation reactions have high energy requirements.(1) Glucoronide conjugation is the most important syn-thetic reaction. Compounds with a hydroxyl or carboxylic acid group are easily conjugated with glucuronic acid,which is derived from glucose, e.g. chloramphenicol, aspirin, morphine, metronidazole, GCS, bilirubin, thyroxine.Drug glucuronides, excreted in bile, can be hydrolyzedin the gut by bacteria, producing beta-glucuronidase.

The liberated drug is reabsorbed and undergoes the samefate. This enterohepatic recirculation of some drugs (e.g.chloramphenicol, phenolphthalein, oral contraceptives) prolongs their action.

(2) Acetylation. Compounds having amino or hydrazineresidues are conjugated with the help of acetyl CoA, e.g.sulfonamides, isoniazid. Multiple genes control the acetyltransferases and rate of acetylation shows geneticpolymorphism (slow and fast acetylators).

(3) Sulfate conjugation. The phenolic compounds andsteroids are sulfated by sulfokinases, e.g. chloramphenicol, adrenal, and sex steroids.

The two phases of drug metabolism

Synthetic (conjugation) reactions:

(4) Methylation. The amines and phenols can be methylated. Methionine and cysteine act as methyl donors.Examples: adrenaline, histamine, nicotinic acid.

(5) Ribonucleoside/nucleotide synthesis is importantfor the activation of many purine and pyrimidine antimeta-bolites used in cancer chemotherapy, e.g. Xeloda®.

(6) Only a few drugs are metabolized by enzymes ofintermediary metabolism. Examples: •alcohol by dehydrogenases•allopurinol by xanthine oxidase•succinylcholine and procaine by plasma cholinesterase•adrenaline by monoamine oxidase (MAO)

FIRST PASS (PRESYSTEMIC) METABOLISM

This refers to metabolism of a drug during its passagefrom the site of absorption into systemic circulation. Allorally administered drugs are exposed to drug metabo-lism in the intestinal wall and liver in different extent. •High first pass metabolism: propranolol, verapamil, pethidine, salbutamol, nitroglycerine, morphine, lidocaine.•Oral dose of these drugs is higher than sublingual or parenteral dose. •There is individual variation in the oral dose due to differences in the extent of first pass metabolism.•Oral bioavailability is increased in patients with severe liver disease.

IV. EXCRETIONIV. EXCRETION

Excretion is the passage out ofsystematically absorbed drugs. Drugs and their metabolitesare excreted in:urine (through the kidney)•bile and faeces•exhaled air•saliva and sweat•milk•skin

The kidney is responsible for excreting all water soluble substances.

Glomerular filtration. Glomerular capillaries have largepores. All nonprotein bound drugs (lipid soluble or insoluble)presented to the glomerulus are filtrated. Glomerular filtrationof drugs depends on their plasma protein binding and renal blood flow. Glomerular filtration rate (g.f.r.) declines progressively after the age of 50 and is low in renal failure.Tubular reabsorption. Lipid soluble drugs filtrated at theglomerulus back diffuse in the tubules because 99% ofglomerular filtrate is reabsorbed, but nonlipid soluble and highly ionized drugs are unable to do so.

Thus, the rate of excretion of such drugs, e.g. aminoglycoside (amikacin, gentamicin, tobramycin) parallelsg.f.r. Changes in urinary pH affect tubular reabsorption of partially ionized drugs:

•Weak bases ionize more and are less reabsorbed in acidic urine.•Weak acids ionize more and are less reabsorbed in alkaline urine.

This principle is utilized for facilitating elimination of drugs in poisoning:•Urine is acidified in morphine and atropine poisoning. •Urine is alkalized in barbiturate and salicylate poisoning.

The effect of changes in urinary pH on drug excretionis greatest for a drug having pK values between 5 to 8,because only in this case pH dependent passivereabsorption is significant.

Tubular secretion is the active transfer of organic acidand bases by two separate nonspecific mechanisms, which operate in the proximal tubules:•Organic acid transport for penicillins, probenecid, salicylates, uric acid, sulfinpyrazones, nitrofurantoin, methotrexate, drug glucuronides, etc.•Organic base transport for thiazides, quinine, procainamide, cimetidine, amiloride, etc.

Many drug interactions occur due to competitionfor tubular excretion, e.g.:•Aspirin blocks uricosuric action of probenecid and sulfin- pyrazone and decreases tubular excretion of methotrexate.•Probenecid decreases the urine concentration of nitrofurantoin, increases the duration of penicillin action and impairs excretion of methotrexate.•Quinidine decreases renal and biliary clearance of digoxin by inhibiting efflux carrier P-gp.

Tubular transport mechanisms are not well developed at birth. Duration of action of many drugs (penicillins, cephalospoins, aspirin, etc.) is longer in neonates. These systems mature during infancy.

•aminoglycosides•beta-lactams•sulfonamides•quinolones•nitrofurans•polymyxins

τ – dosing interval in healthτ – dosing interval in kidney damage

For drugs excreted in the urine:For drugs excreted in the urine:

ττ = ( = (ττ.t.t1/21/2//tt1/21/2))

tt1/21/2 – plasma half-life in healthtt1/21/2 – plasma half-life in kidney damage

•macrolides•lincosamines•rifampicin•tetracyclines (p.o.)

•General inhalation anaesthetics•Potassium iodide•Broncho- antiseptic oils•Alcohol

Rauwolfia serpentina(Reserpine: India)

•sulfonamides•barbiturates•reserpine•alcohol•Coffeinum (Caffeine)

•oleandomycin•spiramycin•phenytoin•zalcitabine•verapamil

Saliva excretion

Morphine(10% stomach excretion)•morphine pKb: 7.9•stomach pH: 1–2 •plasma pH: 7.36

Poppy

KINETICS OF ELIMINATION (elimination = metabolism + excretion)

Clearance (Cl) of a drug is the volume of plasmafrom which the drug is removed per unit time:

Cl = Rate of elimination/Plasma concentration Renal (Clr) or creatinine clearance (Clcr) calculates:

Clrenal = --------------------Cplasma

Curine x Vurine

First order (exponential) kinetics. For majority of drugsthe processes involved in elimination are not saturatedover the clinically obtained concentrations. These drugshave first order kinetics. Their rate of elimination is directly proportional to plasma drug concentration andtheir clearanceremains constant.

Semilog plasmaconcentration-timeplot of a drug eli-minated by first order kineticsafter i.v. injection.

Zero order (linear) kinetics. In a few cases where the drugs are inactivatedby metabolic degradation (such as ethanol, phenytoin, theophylline, salicylates, and warfarin),the time-course of disappearance of the drug from the plasma does not follow the exponential or biexponential pattern, but is initially linear. These drugs are removed at a constant rate which is independent of plasma concentration.This is often called zero order kinetics.

The blood alcoholconcentrationfalls linearly andthe rate of falldoes not varywith dose.

Plasma half live (t1/2) is the time in which the plasmaconcentration of a drug declines by one half. Drug withlong t1/2 can accumulate. Plasma t1/2 of some drugs:

Adenosine < 2 secDobutamine – 2 minBenzylpenicillin – 30 minAmoxicillin – 1 hParacetamol – 2 hAtenolol – 7 hDiazepam – 40 hEthosuccimide – 54 hDigitoxin – 168 h

From the peak plasma concentration the drug is vir-tually eliminated from the plasma in 5 t1/2 periods:

(1) (2) (3) (4) (5)