Study Questions- Drug Metabolism

1. List the Phase I oxidation reactions that occur.

Oxidation Reactions
• Aromatic Hydroxylation
• Aliphatic Hydroxylation
• Dealkylation: O-, N-, S-
• Deamination
• Desulfuration
• Dehalogenation

2. Compare the characteristics of extrahepatic drug metabolism with those of hepatic metabolism
(enzyme activity, substrate specificity, regulation).

Extrahepatic drug metabolism compared to the liver is…

• Contains less enzyme activity
• Greater substrate specificity
• Independently regulated
• Possibly different metabolites

3. Describe the components that must be present for cytochrome P450 to metabolize a substrate.

• Heme protein
• NADPH P450 reductase
• Phosphatydyl choline (structure)
• NADPH (provides e-)
• Oxygen

4. Indicate the subcellular location of cytochrome P450 and enzymes involved in phase II reactions.

P450 often found on smooth endoplasmic reticulum or when this breaks apart to form microsomes.

Phase II enzymes may be located in [smooth] microsomes (A small particle in the cytoplasm of a cell, typically
consisting of fragmented endoplasmic reticulum), cytosol, or mitochondrial membrane.

Microsomes arising from rough ER tend to dedicate their function to protein synthesis while those arising
from smooth ER typically are rich in enzymes.

5. For CYP2D6, describe what the 2D6 refers to.

2D6 refers to the family, subfamily, and gene, respectively.

If there is a P# (ex. CYP2D6P1) it indicates a pseudogene, and is not an actual functional form of P450.

6. Which CYP isozymes are most important (quantitatively) for drug metabolism and which are most
important for xenobiotic (toxins and carcinogens) metabolism.
Drug metabolism – CYP3A4, 3A5, 2D6
Xeonbiotic – CYP1A1, 1B1, 2A, 2B, 2E

7. What is the importance of a mutation in serum pseudocholinesterase for patients who have been
treated with succinylcholine?

The mutated pseudocholinesterase has a decreased activity and leads to a prolonged muscle relaxant effect
that may lead to apnea (breathing problems).

8. For each conjugation reaction, list the enzyme which carries out the reaction, the cofactor
which ultimately becomes conjugated to the substrate, and the cellular location of the enzyme.

Type of Conjugation Reactant Enzyme Location

Glucuronidation UDP glucuronic acid UDP Microsomes
(glucoruonide) glucuronyltransferase
N-Acetylation Acetyl-CoA N-acetyltransferase Cytosol
(acetyl group)
Glutathione Conjugation Glutathione (GSH) GSH-S-Transferase Cytosol/Microsomes
(whole molecule)
Glycine Conjugation (Amino Acid Glycine Acyl-CoA glycinetransferase Mitochondria
Conjugation) (amino acid)
Sulfate Conjugation Phosphoadenosyl- Cytosol
phosphosulfate Sulfotransferase
(Sulfate)
Methylation S-adenosyl-methionine Transmethylases Cytosol
(methyl group)

9. How do the reactions catalyzed by the microsomal form of glutathione S-transferase differ from
those catalyzed by the cytosolic glutathione S-transferase?

Microsomal – prostaglandins/leukotrienes
Cytosolic – xenobiotic conjugation

10. What is the basis for the slow acetylator phenotype compared to the fast acetylator phenotype?

The defect in slow acetylators appears to be caused by the synthesis of fewer enzymes rather than of an
abnormal form of it.

11. How does methylation alter a substrate compared to the other types of conjugates that can be
formed?

Methylation actually makes the substrate LESS polar and therefore facilitates its reabsorption.

12. Give two examples of nuclear receptors involved in the induction of cytochrome P450 isozymes.
For each, list the ligand that binds to the receptor and the isozyme whose expression is altered.

Omeprazole – aryl hydrocarbon receptor – CYP1A1, CYP1A2 induced

Rifampin – pregnane X receptor – CYP3A4 induced
13. List two different drugs which act as inhibitors of cytochrome P450. Describe the mechanism of
inhibition for each inhibitor.

(Carbon monoxide may also bind to heme rendering the enzyme inactivated)
Erythromycin – metabolite binds to heme  inhibition
Chloramphenicol – metabolite binds to P450 protein  inhibition

14. How can potential toxicity associated with the slow acetylation of isoniazid be prevented?

The toxicity is due to interference with pyridoxine and its activities. If pyridoxine is administered the
neural toxicity may be avoided (and will not negatively affect those patients that are not slow acetylators).

15. Why is it important to understand species differences regarding phase I and phase II pathways in
rodents, small animals, and humans?

If these are understood they can be applied to human situations? (I don’t know that answer)

16. Describe the reactions that result in the production of therapeutically active and toxic metabolites
from benzopyrene and cyclophosphamide.

Benzopyrene
• Two initial epoxides may form, one leading to an active metabolite (becomes dihydrodiol) and
the other that becomes a carcinogen (remains an epoxide)
• Two different paths

Cyclophosphamide
• Cyclophosphamide  Aldophosphamide  Phosphoramide mustard (Therapeutic benefit) +
Acroleim (bladder toxicity)
• In this case aldophosphamide is metabolized into two pieces, one with toxicity and the other
without

17. Under what circumstances did treatment with terfenadine result in potentially fatal cardiac
arrythmias?

When administered with Erythromycin and/or ketoconazole (both P450 inhibitors) terfenadine would
build up in the body and possibly cause fatal cardiac arrythmias. (now just given as fexofenadine – active
metabolite)

18. What is the basis for the selective action of parathion as an insecticide?

Humans have an esterase that is able to inactivate the “activated” pesticide while insects do not have this
esterase.

19. Give four examples of how drug action can be altered by pharmacokinetic or pharmacodynamic
changes.

Pharmacokinetic
• Pre-absorption
o Tetracyclines – divalent cations create poorly absorbed complexes
 o Pennicillin/Gentamycin – cannot make contact because PenVK deactivates Gent
o Cisplatin binds aluminum – utilize administration sets that do not contain aluminum
• Absorption
o Ketoconazole – soluble at acidic pH
o GI Flora affected by broad spec abx (enterohepatic cycling)
o Gastric motility (time until peak – what if rapid peak necessary or toxic)
• Distribution
o Plasma protein binding – warfarin displaced by other drugs such as furosemide; resistance
in cancer patients (more alpha1-acid protein)
o Inhibition of transport of export (PGP)
• Metabolism
o Inhibition or Induction of P450
• Excretion
o Inhibition of active secretion – ex probenacid competes with PenVK for same transporters
resulting in increased half-life of PenVK

Pharmacodynamic
• Common Receptor
o Pindolol is given when hypotension caused by overdose of BP med (Intrinsic
Sympathicomimetic Ability – blocks other drug while exhibiting slight agonistic effect)
o Same effect – warfarin and aspirin both thin the blood
o Antagonistic effects – warfarin (thinning) and Vit K (clotting)

20. Compare infants and the elderly with respect to changes in drug absorption, distribution,
metabolism and excretion.

Absorption
• Infants – low gastric acid/prolonged gastric emptying time
• Elderly – decreased splachnic blood flow/changes in GI motility
Distribution
• Infants – inc body water, dec plasma protein, dec body fat
• Elderly – dec body water, dec plasma protein (sometimes), inc body fat
Metabolism
• Infants – generally low activity
• Elderly – dec metabolic capability, dec liver mass, dec hepatic blood flow
Excretion
• Infants – decreased renal blood flow, dec secretion, [relatively decreased GFR]
• Elderly – decreased renal blood flow, dec secretion, dec GFR

21. Why is the development of tolerance to opioids potentially very dangerous?

Tolerance to the euphoric effect generally builds faster than the respiratory depression tolerance.
Suffocation

22. How do the symptoms associated with withdrawal from drug dependence relate to the therapeutic
effects of the drug?
Basically the opposite.

Depressant (ethanol-barbituate type) – convulsions, significant mortality if untreated

Opiate (narcotic-analgesic) – autonomic hyperactivity
Caffeine – headache
Cocaine – depression