General Pharmacology Send

1 Chapter I IN O U TIO TR D C N
WHAT IS PHARMACOLOGY The term is derived from the Greek word "Pharmakon" (English: Pharmacon) meaning a 'Drug' and "Logos" meaning a 'Science'. So, in short, Pharmacology can also be defined as a science of drugs. WHAT IS A DRUG Drug (French: Drogue - a dry herb): Drug is the single active chemical entity present in a medicine that is/used for diagnosis, prevention, treatment/cure of a disease. As per THE DRUGS AND COSMETICS ACT, 1940 Drug is define as all medicines for internal or external use of human beings or animals and all substances intended to be used for or in the diagnosis, treatment, mitigation or prevention of any disease or disorder in human beings or animals, including preparations applied on human body for the purpose of repelling insects like mosquitoes. WHO Scientific Group [Wld. Hlth. Org. Techn. Rep., Ser 341, p. 7 (1966)] has defined the drug as "any substance or product that is used or intended to be used to modify or explore physiological systems or pathological states for the benefit of the recipient." Benefit of the recipients includes: Cure: Antibiotics are used to cure from infectious diseases Control: Insulin is used to control Diabetes Mellitus Prevention: Mefloquine is used for prevention of Malaria Diagnosis: Barium sulfate is used for the diagnosis of PUD
General pharmacology
2 SOURCES OF DRUGS 1. Plant Source Alkaloid: Alkaloids are basic nitrogenous substance of plant origin and produces salt when it combines with acids5. The name of Alkaloids ends in ine Belladonna alkaloid: Atropine, Scopolamine Cinchona alkaloid: Opium alkaloid: Ergot alkaloid: Vinca Alkaloid: Cocaine Alkaloid: Quinine, Quinidine Morphine, Codeine Ergotamine Vinblastine, Vincristine Lignocaine
Glycoside: The glycoside is a condensation product of sugar with various kinds of organic hydroxyl compound (non sugar part). The name of Glycoside end in in. Cardiac glycoside, Digoxin, Digitoxin Aminoglycosides: Streptomycin, Gentamicin (Antibiotics) Oil: It may be fixed or volatile Fixed oil: Olive oil: can be used as emollient Castor oil: Used as Cathertic agent Volatile oil: Peppermint oil: Used as solvent and flavouring agent
3 Clove oil: It relieves pain
4 Gum and Mucilage: Mucilage is a physiological product and Gum is a pathological product of plant. Some are used as Laxative agent (Agar,Psyllium) and emulsifying agent(Gum acacia) and some are used as adhesive. 2. Animals e.g., Insulin, thyroid extract,heparin, gonadotrophins, and antitoxic sera. 3. Micro-organisms: Bacteria and fungi, isolated from soil, are important sources of antibacterial substances, e.g., penicillin. 4. Mineral Source: Iron, Calcium, Magnesium. Liquid paraffin, and kaolin 5. Synthetic: e.g., Analgesics, hypnotics, anticancer drugs and antimicrobials. Majority of the drugs currently used in therapeutics are synthetic 6. Genetic engineering (DNA recombinant technology), e.g., human insulin and growth hormones 7. Hybridoma technique e.g., monoclonal antibodies. DRUG CATEGORIES Non-prescription Drugs (OTC drugs). These are safe and can be sold over the counter without prescription, e.g. vitamins, antacids etc. Prescription Drugs These are classified in various schedules and are used under medical supervisor and dispensed by an order of a registered medical practitioner, e.g. antibiotics, anxiolytics, anti-depressants etc. Orphan drugs: drugs or biological products for diagnosis /treatment/prevention of rare diseases or condition or a more common disease for which there is no reasonable expectation that the cost of development and marketing it will be recovered from the sale. Eg: liothyronine, digoxine immune fab.
5 Orphan drug Acetyl cysteine Orphan disease For paracetamol overdose Aminosidine Anagrelide For kala azar For polycythemia Vera
Established drug: Drugs and vaccines which have been in use for a long time and are already included in some official pharmacopoeia ( e.g. BP, USP) are known as established drug Prodrug: Some chemical substances do not produce pharmacological effect until they are chemically altered Example: Prodrug Levodopa. Prednisone Bacampicillin Active form Dopamine Prednisolone Ampicillin with in the body. Such chemical substances are called prodrugs.
Biological drugs: Those drugs obtained from living sources are termed as biological drugs. Heparin, Insulin, Vaccine etc are examples of biological drugs. Biological drugs are protein in nature and cant be given orally. Sometimes they are antigenic and more prone to hypersensitivity reactions
6 P- Drug (Personal drug/ Priority drug): P-drugs or priority drugs are the drugs those have been chosen by prescribers to prescribe regularly. These are the drugs of priority for a given indication. It varies from country to country and between doctors due to:
Placebo drug/ Medicine(Placebo): A Placebo is any component of therapy that is without specific biological activity for the condition being treated1. It is an inert substance which is given in the garb of a medicine. It works by psychological rather than pharmacological means and often produces responses equivalent to the active drug. Placebos are used in two situations:
7 a. As a control device in clinical trial of drugs b. To treat a patient who in the option of the physician, does not require an active drug. Nocebo: It is the converse of placebo, and refers to negative psychodynamic effect evoked by loss of faith in the medication and/or the physician. Nocebo effect can oppose the therapeutic effect of active medication Essential Drugs (EDs): In a given situation the drugs which are called essential are the most needed drugs, to satisfy the health needs of vast majority of the population. They should be made available in proper dosage forms, at all the times in adequate amounts, in acceptable quality and at a price that people can afford Controlled drugs: Narcotics and Psychotropic drugs produce dependence and are addictive on continued use. Special regulatory controls and prescription requirement5s are applicable for such drugs under drug legislations to prevent their misuse. These drugs are called controlled drugs. Their manufacture, import, supply, possession and prescription are also subject to control under The Narcotic Control Act ,1990. Control drugs are again graded according to degree of harmfulness into: A-class controlled drug: Morphine, Pethidine, Codeine B-class controlled drugs: Amphetamine and related drugs C-class controlled drugs: Benzodiazepines (alprazolam, bromazepam, and diazepam) DRUG NOMENCLATURE Every drug has three types of names. Chemical Name: This is a name given according to the chemical constitution of a drug. Non-proprietary or Generic Name: These names are used uniformly all over the world by an International agreement through the WHO. When included in an official pharmacopeia, the nonproprietary name becomes an official name. The non-proprietary name is very frequently referred to
8 as generic name. These names are assigned by the United States Adopted Name (USAN) Council, only when the drug has been found to be of potential therapeutic usefulness.
9 Non proprietary name or Generic name are Chosen by official agencies. It is concise and meaningful. INN: International Nonproprietary Names BAN: British Approved Names USAN: United States Approved Names The nonproprietary name of some drugs in USA and UK is different In UK Paracetamol Adrenaline Rifampicin Lignocaie Thiopentone In USA Acetaminophen Epinephrine Rifampin Lidocaine Thiopental
Proprietary or Trade or Brand Name: The trade name selected by the pharmaceutical company to market the non-proprietary drug .The name is a copyright or registered name of the drug by which it is sold by any drug company. For example:acetyl salicylic acid is the chemical name while aspirin is the generic name and ecospirin is the trade name of the drug
10 BRANCHES OF PHARMACOLOGY Pharmacy: The science of identification, selection, preservation, standardization, compounding and dispensing of medicinal substance Pharmacotherapeutics: is the application of pharmacological information together with the knowledge of the disease for its prevention, mitigation or cure. Clinical pharmacology: It is the scientific study of drugs in man. Chemotherapy: Chemotherapy is the treatment of systemic infection or malignancy with specific drugs that have selective toxicity for the infective organism/malignant cell with no/minimal effect on the host cells. Toxicology: Toxicology is the study of poisonous effect of drugs and other chemicals with emphasis on defection, prevention and treatment of poisoning. Pharmacoepidemiology: branch of pharmacology which deals with the study of the use and effects of drugs in large numbers of people. Pharmacoeconomics: branch of pharmacology which deals with the analysis of the cost of therapy to the health care system and the society Pharmacovigilance: branch of pharmacology which deals with the process of identifying and responding to the issues of drug safety trough the detection of drug effects, R% adverse Pharmacogenetics: branch of pharmacology which deals with the study of inherited (genetically mediated) differences (variation) in metabolism and response of drugs in humans. Clinical pharmacy, involves cooperation of pharmacist with the physician in educating patient about compliance and counseling on how to take the medication, and monitor the errors in taking the drugs. Biochemical Pharmacology: Describes the action of drug on the biochemical process within the cell.
11 Molecular Pharmacology: Deals with action of drug at molecular level Neuropharmacology: Deals with action of drug on CNS Cardiovascular Pharmacology :Deals with action of drug on CNS Immunopharmacology: Deals with immunological aspects of drug action Toxicology: It deals with the undesirable, harmful effects of drug on living body.
12 CHARACTERISTICS OF DRUGS 1. Physical and chemical nature: Drugs may be: Solid, Liquid or Gaseous Chemically drugs are weak acids or weak bases. This has got importance because PH differences in the various compartments of the body may alter the degree of ionization of such drugs. Weak acidic drugs are better absorbed in acidic media (Stomach) and weak basic drugs are better absorbed in basic media (Duodenum). Acidic drugs Adrenaline Ampicillin Aspirin Morphine Levodopa 2. Molecular Weight: MW ranges from 100-1000 Penetration of biological membrane depends on MW MW Less than 600 crosses placental barrier MW less than 300 excreted through kidney and more than 300 are excreted through bile Drugs much larger than MW 1000 will not diffuse readily between compartments of the body. So they must be administered into the compartment where they have their effect. Alteplase, a clot dissolving enzyme is administered directly into the vascular compartment by intravenous infusion2. 3. Drug shape: The shape of a drug molecule must be such as to permit binding to its receptor site. Optimally, the drugs shape is complementary to that of the receptor site in the same way that a key is complementary to a lock. Basic drugs Atropine Chloroquine Diazepam Propranolol Pilocarpine
13 4. Lipid solubility: Lipid soluble drugs are easily absorbed through the biological membrane and can pass through BBB. Most of the drugs are lipid soluble. First generation antihistamines, sedatives, antidepressants are lipid soluble drugs. 5. Water solubility: Water soluble drugs can not be absorbed easily through the biological membrane. Aminoglycosides (Gentamicin, Streptomycin) are water soluble drugs and not given orally 6. Ionization of drug: Ionization of drug may markedly reduce their ability to permeate membranes as ionized drug attract water, become polar and form lipid insoluble complex. 7. Pka (Ionization Constant): The PKa of a drug is the PH at which the concentration of nonionized and ionized forms is equal. 8. Potency: If pharmacological effect of one drug is more at lower concentration than another drug it is considered as more potent drug. In case of potent drug the log dose response curve is shifted to the left. Pethidine is 10 times less potent than Morphine Potency refers to the concentration or dose of a drug required to produce 50% of that drugs maximal effect2. The clinical effectiveness of a drug depends not only on its potency but on its maximal efficacy. 12. Half life of drugs Half life (t ) is the time in which the concentration or effect of the drug declines by one half. The time course of drug in the body will depend on both the volume of distribution (Vd) and clearance (CL).
0.693x Vd
CL
(0.693 = Natural log of 2)
14 Vd and CL are again calculated as follows: Total amount of drug in the body Vd = Concentration of drug in plasma Rate of elimination CL= Concentration of drug If the drug is given by bolus injection plasma concentration will rise quickly as drug enters the blood to reach a peak. Then there will be a sharp drop as the drug distributes round the body (Distribution phase). It will be followed by a steady decline as drug is removed from the blood by the liver or kidneys (Elimination phase). The distribution phase is known as alpha half life (t a) and the elimination phase is known as beta half life (t B). t beta is therapeutically more important than t alpha. Half life is also divided into Plasma half life, Biological or elimination half life, and Biological effective half life. When a drug is given at a constant rate the time to reach steady state depends on the t and for all practical purposes after 5t s the amount of drug in the body will be at a plateau. Elimination from the plasma also completed after 5 t time. For drugs eliminated by first order kinetics t remains constant as Vd and CL do not change. Most of the drugs are excreted by first order kinetics. For drugs eliminated by zero order kinetics t increases with dose as clearance progressively decreases.
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Factors affecting half life: Route of administration, Diffusion into the tissue, Plasma protein and tissue binding Metabolism, Excretion, Disease states Importance: Half life gives idea about, Duration of action of drug, Amount of drug to be administered, Frequency of administration, Management of drug overdose, Presence of disease in the organ of metabolism or excretion.
16 Chapter II GENERAL PHARMACOLOGY Pharmacology: Pharmacology is the science of drugs which deals with interaction of exogenously administered chemical molecules with living system. It encompasses all aspects of knowledge about drugs, but most importantly those that are relevant to effective and safe use for medicinal purposes. PHARMACOLOGY COMRISES OF TWO MAIN ASPECTS Pharmacodynamics & Pharmacokinetics Pharmacodynamics: (What the drug does to the body): Pharmacodynamics includes the study of physiological and biochemical effects of drugs and their mechanism of action at macromolecular / sub cellular / organ system level. Pharmacokinetics: (What the body does to the drug): Pharmacokinetics refers to the quantitative study of movements of the drug in and alteration of the drug by the body including absorption, distribution, binding/localization/storage, biotransformation and excretion of the drug.
17 Chapter III ROUTES OF DRUG ADMINISTRATION For any drug to exert its pharmacological effects, it must reach its site of action. This usually entails its translocation or biotransformation across the cell membranes, which cannot be achieved unless the drug is purposely administered to produce its effects systemically or locally. The choice of route of administration depends on: The choice of an appropriate route in a given situation depends on the drug as well as patient factors. ( Factors governing ROA) 1. Physical and chemical characteristics of the drug and its formulation (solid/liquid/gas, suspension or an oil, stability and irritancy ) for example highly irritant drugs or those unstable in gastric acidic PH cannot be given by oral route hence preferred route will be parenteral route First pass metabolism: Whether the drug is absorbed from stomach and intestine or whether it is liable to first pass degradation.drugs which undergo high Ist pass metabolism are not given by oral route. GTN not given orally as it undergoes high first pass metabolism Gastric HCL stability: Benzyl penicillin not given orally as it is destroyed by gastric HCL Gastric enzyme stability: Insulin is not given orally as it is destroyed by enzymes Lipid/Water solubility: Amino glycosides not given orally as they are water soluble and not absorbed if given orally Site of action: Drugs are sometimes given directly to site of action Onset of action: For rapid onset of action intravenous or inhalation route may be chosen General pharmacology
18 Adverse effects: To avoid adverse effects sometimes route are selected. Salbutamol well tolerated if given inhalationally
2. The desired action (local or systemic), 3. Clinical emergency or routine treatment, (rapidity with which the drug response is desired) like for emergency action IV route is preferred and for routine treatment oral or route which allow self medication is preffered 4. Condition of the patient (unconscious or vomiting) oral administration is not possible preffered is parenteral one 5. Accuracy of dose required, such cases IV is preferred More detail examples are given below The major routes of drug administration are classified below based on the effects is required is systemically or locally
1 Local Topical Routes Deeper tissue administration Intra Arterial Systemic route I. Enteral Routes Oral Sublingual Rectal II. Parenteral Routes Intravenous Intramuscular Intraperitoneal Intrathecal Intramedullary Intra-articular Subcutaneous Inhalation
2 LOCAL ROUTE OF ADMINSTRATIONS Local route of drug administration are used in case of localized lesions at accessible site or for the drugs whose systemic absorption is minimal or absent. Merits: systemic side effects are absent, safe and convenient Demerits: can cause irritation at the site of application. 1. Topical application: it is the external application of drugs to the surface for localized action. e.g. lotions, ointments (innuction), dusting powders, sprays etc. Non absorbable drugs are given orally for their localized action in some parts of the G.I.T e.g. sucralfate for peptic ulcer, sulfasalazine for ulcerative colitis Irrigating solutions and jellies are applied to the body cavities for local antiseptic action e.g povidone iodine in to urethra 2. Deeper tissue: deep areas are approached using syringe and needle and these drugs donot undergo systemic absorption form the site of administration e.g. hydrocortisone acetate by intra articular inj also by retrobulbar inj. 3. Intra arterial; close intra arterial inj. are used for localized action like administration of contrast media in angiography and anti cancer drugs in to femoral or brachial artery for limb malignancies SYSTEMIC ROUTES OF ADMINSTRATION System route are for those drug which are intended to be absorbed in to systemic circulation and distribute all over the body including the site of action. ENTERAL ROUTES Placement of a drug directly into any part of the gastrointestinal tract is called an 'enteral' mode of administration ( enteron = an intestine).
1. Oral Administration Site: Swallowing a drug through mouth. Merits: Most commonly used method as it is safe, convenient and painless procedure. Besides, it is economical as sterilization of drug products is not essential.If overdosed it is possible to remove the un absorbed drug to prevent toxicity. Demerits: (i) Drugs have slower onset of action as their absorption is slow and erratic. Many drugs being highly polar (e.g. aminoglycoside group of antibioticsstreptomycin) or being quarternary salts (e.g. d-tubocurarin and suxamethonium) are not absorbed and hence cannot be given orally to provide systemic effects, (ii) Drugs that are destroyed by digestive juices (e.g. penicillin-G, insulin, oxytocin and testosterone) cannot be administered by this route, (iii) Drugs having first pass effect, i.e. those destroyed in liver before reaching systemic circulation (e.g. morphine, isoprenaline) are not preferred to be given by this route, (iv) Palatability of drugs is essential and (v) Drugs cannot be given by this route to an unconscious and uncooperative patient or to a patient having nausea, vomiting and diarrhoea. Examples with Dosage Forms: Majority of drugs in solid dosage forms (e.g. tablets, capsules and powders) or in liquid dosage forms (syrups, elixirs and mixtures) are usually given orally. 2. Sublingual (and buccal) Administration Site: The drug is placed beneath the tongue or crushed in mouth and spread over the buccal mucosa. Merits: (i) Quick onset of action because of rapid absorption taking place through buccal mucosal membrane, (ii) After absorption, the drug passes directly into the systemic circulation, bypassing the portal circulation, thus avoiding first pass degradation and (iii) The drug can be spitted out if side effects are observed. Demerits: (i) Distasteful, irritant drugs cannot be given; (ii) drugs of higher molecular weights are not well absorbed by this route otherwise it could have been an extremely useful method for drugs like insulin or other peptides. General pharmacology
Examples with Dosage Forms: Isosorbide dinitrate tablets and nitroglycerin tablets (for angina); isoprenaline sulfate tablets (for bronchial asthma) and nifedipine in powder form (after crushing the capsule, for hypertension). 3. Rectal Administration Site: Through rectum. Merits: (i) Can be useful for patients having nausea and vomiting, (ii) First-pass degradation is largely bypassed as a major portion of the drug is absorbed from external haemorrhoidal veins and (iii) Useful for gastric irritant drugs also. Demerits: (i) Chances of rectal inflammation, (ii) Absorption is unreliable and (iii) Inconvenient and embrassing to the patient. Examples with Dosage Forms: (i) For local effects: Dulcolax and glycerine suppositories; enemas and ointments, (ii) For systemic effects: aminophylline (bronchodialator) and indomethacin (antiinflammatory agent) suppositories. 4. PARENTERAL ROUTES Routes other than "enteral" are called `parenteral' routes of administration (par = aside from). Thus the administrations of drugs by injection are commonly termed as parenteral preparations. a. Intravenous Administration Site: Through lumen of the veins. Merits: (i) As the drug enters the systemic circulation directly, bypassing first pass degradation, there is a quick onset of action and a lesser dose is required to achieve the desired plasma concentration (valuable in emergency), (ii) Can be employed even in unconscious, uncooperative patients and in those having nausea, vomiting and diarrhoea, (iii) Hypertonic solutions and GIT irritant drugs can also be infused by this route, (iv) Large volume of fluids can be infused at a uniform
5 rate by this route and (v) Amount of the drug can be controlled with an accuracy not possible by any other route.
6 Demerits: (i) Strict aseptic conditions are needed and the patient has to depend on somebody for giving an injection, (ii) Besides being painful, it is risky because once the drug is injected it cannot be recalled. Introduction of any particulate matter or air may produce embolism which may prove fatal, (iii) Drugs in suspension or oily drugs cannot be administered by this route, as a result there are no 'depot injections' available for this route and (iv) Venous thrombosis, and thrombophlebitis of the vein injected and necrosis around the site of injection can result if extravasation occurs. Examples with Dosage Forms: Glucose (GDW), Glucose Normal Saline (GNS), dopamine and norepinephrine drips for I.V. infusion. Many antibiotics, barbiturate anesthetics, diazepam, heparin etc. are injected by this route. b. Intramuscular Injection Site: Deltoid muscle or gluteal mass of left or right buttock. Vastus muscle underlying the lateral surface of the thigh may also serve as an alternate area. Merits: (i) Absorption is more predictable, less variable and rapid compared to oral route and (ii) Depot injections can also be given by this route, for obtaining sustained drug effects. Demerits: (i) Perfect aseptic conditions are needed, (ii) Chances of abscess at the site of injection, (iii) Chances of nerve damage leading to paralysis of muscle supplied by it and (iv) Large volumes cannot be administered (a maximum of 5 to 10 ml can be given). Examples with Dosage Forms: Various antibiotics, antiemetics and depot injection of testosterone, and neuroleptics (haloperidol and perphenazine depot injection). c. Intraperitoneal Administration Site: Into the peritoneal space. Merits: Rapid absorption due to larger surface area. Demerits: Painful, risky due to chances of adhesions and infections in peritoneal cavity (peritonitis). Aseptic conditons are needed. General pharmacology
7 Examples with Dosage Forms: Less in use except for giving antirabies injection or for peritoneal dialysis in cases of poisoning and renal failure. Most commonly used procedure for administering drugs in laboratory animals. d. Intrathecal (intraspinal) Administration Site: Into the subarachnoid space. Merits: The drug after diffusing from the lumbar sac passess into the subarachnoid space, bypassing the blood brain barrier and blood-CSF barrier. Thus significant CSF levels are provided which otherwise are not possible by any other route. The drug acts directly on meninges and the CNS. Demerits: Strict aseptic conditions and great expertise is needed to give such injections. Moreover it is a painful and risky procedure. Examples with Dosage Forms: (i) Many radiopaque contrast media for myelography (to visualise spinal cord) (ii) Xylocame injection for providing spinal anaesthesia. Mainly provide local effects but certain antibiotics used to treat infectious meningitis do provide systemic effects when given by this route. e. Intramedullary Administration Site: Injection into the tibial or sternal bone marrow. Merits: Onset of action very fast as the vascular spaces of bone marrow communicate directly with the large veins. Demerits: Risky, painful, strict aseptic conditions are needed and skill is also needed to give such injections. Examples with Dosage Forms: Bone marrow transplantation. Sometimes blood is also transfused,by this route, specially in children, if veins are not available. f. Subcutaneous Administration Site: Injection into the subcutaneous tissue under the skin.
8 Merits: (i) Smooth but slower absorption for a longer period compared to intravenous. or intra-muscular route, (ii) Depot injections can also be given. Demerits: (i) Suitable for only small volumes of drugs (maximum 2 ml.), (ii) Irritant drugs cannot be administered as sloughing and necrosis may result, (iii) Not suitable in the states of shock as reduced peripheral circulation decreases the rate of absorption. Examples with Dosage Forms: Subcutaneous injection of local anesthetics (for local effects) and of Insulin (for systemic effects). Vaccines are administered preferably by this route. g. Intradermal (intracutaneous) route The drug is injected into the outer layers of skin. The amount of drug given is small and absorption is slow. A tuberculin syringe is used to give such an injection. Example: Injection of BCG vaccin e, diagnostic tests and allergic sensitization testing in patients h. Dermojet injections It is a subcutaneous needleless injection of a drug by means of a high velocity jet projected through a microfined orifice. It is a painless procedure useful for mass inoculation. i. Inhalation Site: Inspiration through nose or mouth. Merits: (i) Faster absorption and hence quick onset of action due to larger surface area of alveoli and (ii) Self administration is also possible. Demerits: Bronchial irritation leading to increased bronchial and salivary secretions. Examples with Dosage Forms.- Oxygen and general anaesthetics inhalation (for systemic effects); metered aerosol preparations of salbutamol and isoprenaline for treatment of bronchial asthma and inhalation of sodium chromoglycate through spin inhaler as prophylaxis to bronchial asthma (local effect).:
9 j. New drug delivery systems For better patient compliance and to improve the drug delivery, at the site where it is required, special drug delivery systems have recently been developed which have an added advantage of prolonged duration of drug action. Some of these systems are: Transdermal Patches (transdermaldrug delivery system,TDDS) Site: Adhesive matrix (Patch) containing drug is applied to chest, upper abdomen, or mastoid region. Merits: Slow but sustained release of the drug for several days. Demerits: Nil; however, if irritation results the site of application can be changed. Examples with Dosage Forms: Nitroglycerin (for angina), scopolamine (for motion sickness) and clonidine (for hypertension) transdermal patches for systemic effects. In these the drug is incorporated in to a polymer(polyisobutylene) which in turn is bonded to an adhesive plaster. The drug is delivered at the skin surface by diffusion, for percutaneous absorption into circulation. These preparations are designed to provide steady and smooth plasma concentration of the drug for a period ranging from 1-3 days from the site of their application. k. Ocuserts These are thin elliptical microunits, that con-tam the drug in a reservoir from which the drug slowly released through a membrane by diffusion at a steady rate. For example: Pilocarpine ocusert used in glaucoma: which is placed under the lower eye lid :o deliver pilocarpine fora period of 7 days; thus avoiding the need for instilling eye drops repeatedly every day.
10 l. Liposomes as Drug Carrier Liposomes are used for drug delivery due to their unique properties. A liposome encapsulates a region on aqueous solution inside a hydrophobic membrane; dissolved hydrophilic solutes cannot readily pass through the lipids. Hydrophobic chemicals can be dissolved into the membrane, and in this way liposome can carry both hydrophobic molecules and hydrophilic molecules. To deliver the molecules to sites of action, the lipid bilayer can fuse with other bilayers such as the cell membrane, thus delivering the liposome contents. By making liposomes in a solution of DNA or drugs (which would normally be unable to diffuse through the membrane) they can be (indiscriminately) delivered past the lipid bilayer. There are three types of liposomes MLV (multilamellar vesicles) SUV (Small Unilamellar Vesicles) and LUV (Large Unilamellar Vesicles). These are used to deliver different types of drugs. E.g. Liposomal amphotericin B for Fungal infections and protozoal infections, Liposomal cytarabine for Malignant lymphomatous meningitis, Liposomal daunorubicin for HIVrelated Kaposis sarcoma. The use of liposomes for transformation or transfection of DNA into a host cell is known as lipofection. In addition to gene and drug delivery applications, liposomes can be used as carriers for the delivery of dyes to textiles, pesticides to plants, enzymes and nutritional supplements to foods, and cosmetics to the skin. Liposomes are also used as outer shells of some microbubble contrast agents used in contrast-enhanced ultrasound. m. Prodrugs This is an inactive form of drug which gets metabolised in the body to an active drug. These are used to overcome the pharmacokinetic disadvantage of the useful drug. For example: Dopamine is very useful in treating Parkinson-ism, but it does it does not cross blood-brain barrier. Levodopa, its prodrug, can cross BBB which is then converted to dopamine in the CNS. Prodrug may also be used to provide longer duration of drug action, e.g., esters of penicillins get slowly hydrolysed in the body to provide slow and sustained release of penicillins (Procaine Penicillin-G and Benzathine Penicillin-G).
11 n. Computerized Miniature Pumps These are programmed to release drugs at a definite rate, either continuously as in the case of insulin or intermittently in pulses as in the case of GnRH (gonadotrophin releasing hormone). These pumps may also be provided with glucose sensor devices which trigger insulin on body demands only. o. Monoclonal Antibodies as Drug Carrier Monoclonal antibodies react with a single antigenic determinant (epitope) of any antigen unlike polyclonal antibodies many antigenic determinants (epitope), hence the monoclonal antibodies can be used for site directed delivery of drugs p. Drug-eluting stent (DES) is a peripheral or coronary stent (a scaffold) placed into narrowed, diseased peripheral or coronary arteries that slowly releases a drug to block cell proliferation. This prevents fibrosis that, together with clots (thrombus), could otherwise block the stented artery, a process called restenosis. Drug-eluting stents reduces the chance of renarrowing, or restenosis, of the blood vessel. The stent is usually placed within the peripheral or coronary artery by an Interventional cardiologist or Interventional Radiologist during an angioplasty procedure.Drug-eluting stents in current clinical use were approved by the FDA after clinical trials showed they were statistically superior to bare-metal stents (BMS) for the treatment of native coronary artery narrowings. q. Targeted drug delivery, sometimes called smart drug delivery, is a method of delivering medication to a patient in a manner that increases the concentration of the medication in some parts of the body relative to others. The goal of a targeted drug delivery system is to prolong, localize, target and have a protected drug interaction with the diseased tissue. The conventional drug delivery system is the absorption of the drug across a biological membrane, whereas the targeted release system is when the drug is released in a dosage form. The advantages to the targeted release system is the reduction in the frequency of the dosages taken by the patient, having a more uniform effect of the drug, reduction of drug side effects, and reduced fluctuation in circulating drug levels. The disadvantage of the system is high cost which makes productivity more difficult and the reduced ability to adjust the dosages. There are different types of drug delivery vehicles, such as, polymeric micelles, liposomes, lipoprotein-based drug carriers, nano-particle drug carriers, dendrimers etc. An ideal drug delivery vehicle must be non-toxic, biocompatible, non-immunogenic and biodegradable.
12 Chapter IV ABSORPTION OF DRUGS A drug injected intravascularly (intravenously) directly enters the systemic circulation and exerts its pharmacologic effects. However, majority of drugs are administered extravascularly generally orally. If intended to act systemically, such drugs can exert their pharmacologic actions only when they come into blood circulation from their site of application, and for this, absorption is an important prerequisite step. Drug absorption is defined as the process of movement of unchanged drug from the site of administration to systemic circulation The rate and extent to which the drug that reaches the site of action or in to the body fluids from which it has direct access to the site of action (blood or systemic circulation) in its unchanged form from the site of administration is referred to us Bioavailability(BA). Hence by this definition BA any drug by iv route is 100% but BA is always less by other routes like oral route due to first pass metabolism or incomplete absorption and those by other parenteral route may be less due to local binding of the drugs. MECHANISMS OF DRUG ABSORPTION The principal mechanisms for transport of drug molecules across the cell membrane in order of their importance are: 1. 2. 3. 4. 5. 6. 7. Passive diffusion Pore transport Facilitated diffusion Active transport Ionic or electrochemical diffusion Ion-pair transport Endocytosis
13 1. Passive Diffusion Also called nonionic diffusion, it is the major process for absorption of more than 90% of the drugs. The driving force for this process is the concentration or electrochemical gradient. The drug molecules diffuse from a region of higher concentration to one of lower concentration until equilibrium is attained along the concentration gradient across the biological membrane. Since the membrane is lipoidal in nature.A lipophilic drug diffuses at a faster rate by solubilizing in the lipid layer of the membrane. The molecular weights of most drugs lie between 100 to 400 daltons which can be effectively absorbed passively. The diffusion generally decreases with increase in the molecular weight of the compound. 2. Pore Transport It is also called as convective transport, bulk flow or filtration. The process is important in the absorption of low molecular weight (less than 100), low molecular size (smaller than the diameter of the pore) and generally water-soluble drugs through narrow, aqueous-filled channels or pores in the membrane structure for example, urea, water and sugars. Chain-like or linear compounds of molecular weight upto 400 daltons can be absorbed by- filtration. Drug permeation through water-filled channels is of particular importance in renal excretion, removal of drug from the cerebrospinal fluid and entry of drugs into the liver. 3. Carrier-Mediated Transport Some polar drugs cross the membrane more readily than can be predicted from their concentration gradient and partition coefficient values. This suggests presence of specialized transport mechanisms without which many essential water-soluble nutrients like monosaccharides, amino acids and vitamins will be poorly absorbed. The mechanism is thought to involve a component of the membrane called as the carrier that binds reversibly or noncovalently with the solute molecules to be transported. This carrier-solute complex traverses across the membrane to the other side where it dissociates and discharges the solute molecule. The carrier then returns to its original site to complete the cycle by accepting a fresh molecule of solute. The carrier may be an enzyme or some other component of the membrane
14 4. Facilitated Diffusion It is a carrier-mediated transport system that operates down the concentration gradient (downhill transport) but at a much a faster rate than can be accounted by simple passive diffusion. The driving force is concentration gradient (hence a passive process). Since no energy expenditure is involved, the process is not inhibited by metabolic poisons that Interfere with energy production. Facilitated diffusion is of limited importance in the absorption of drugs. Examples of such a transport system include entry of glucose into RBCs and intestinal absorption of vitamins BI and B 2 . A classic example of passive facilitated diffusion is the GI absorption of vitamin B12. An intrinsic ' factor (IF), a glycoprotein produced by the gastric parietal cells, forms a complex with vitamin B12 which is then transported across the intestinal membrane by a carrier system. 5. Active Transport Active transport is a more important process than facilitated diffusion in the absorption, of nutrients and drugs and differs from it in several respects: The drug is transported from a region of lower to one of higher concentration i.e. against the concentration gradient or uphill transport, without any regard for equilibrium, since the process is uphill, energy is required in the work done by the carrier As the process requires expenditure of energy, it can be inhibited by metabolic poisons that interfere with energy production like fluorides, cyanide and dinitrophenol and lack of oxygen, etc. Endogenous substances that are transported actively include sodium, potassium, calcium, iron, glucose, certain amino acids and vitamins like niacin, pyridoxine and ascorbic acid. Drugs having structural similarity to the endogenous substances are also absorbed by this route. Examples include absorption of 5-fluorouracil and 5- bromouracil via the pyrimidine transport system, absorption of methyldopa and levodopa via an L-amino acid transport system and absorption of ACE inhibitor enalapril via the small peptide carrier system. A good example of competitive inhibition of drug absorption via active transport is the impaired absorption of levodopa when ingested with meals rich in proteins. General pharmacology
15 Active transport is also important in renal and biliary excretion of many drugs and their metabolites and secretion of certain, acids out of the CNS 6. Ionic or Electrochemical Diffusion The charge on the membrane influences the permeation of drugs. Molecular forms of solutes are unaffected by the membrane charge and permeate faster than ionic forms. Of the ionic forms, the anionic solute permeates faster than the cationic form. Thus, at a given pH, the rate of permeation is in the following orderunionized molecules > anions > cations.The permeation of ionized drugs, particularly the cationic drugs, depends on the potential difference or electrical gradient as the driving force across the membrane. A cationic drug is repelled due to positive charge on the outside of the membrane. As a result, only those cations with a high kinetic energy penetrate the ionic barrier. However, once inside the membrane, the cations are attracted to negatively charge intracellular membrane thereby creating an electrical gradient. Such a drug is then said to be moving downhill with electrical gradient. If the same drug moves from a higher to lower concentration, it is said to be moving down the electrical gradient and the phenomena is called as electrochemical diffusion. Like passive diffusion, the process continues until equilibrium is reached. 7. Ion-Pair Transport Yet another mechanism that explains the absorption of drugs like quaternary ammonium compounds and sulfonic acids, which ionize under all pH conditions, is ion-pair transport. Despite their low o/w partition coefficient values, such agents penetrate the membrane by forming reversible neutral complexes with endogenous ions of the GIT like mucin. Such neutral complexes have both the required lipophilicity as well as aqueous solubility for passive diffusion. Such a phenomenon is called as ion-pair transport
16 8. Endocytosis It is a minor transport mechanism which involves engulfing extracellular/materials within a segment of the cell membrane to form a saccule or a vesicle (hence also called as corpuscular or vesicular transport) which is then pinched-off intracellularly This phenomenon is responsible for the cellular uptake of macromolecular nutrients like fats and starch, oil soluble vitamins like A, D, E and K and drugs such as insulin. Another significance of such a process is that the drug is absorbed into the lymphatic circulation thereby by-passing first-pass hepatic metabolism. Endocytosis includes two types of processes: Phagocytosis (cell eating): adsorptive uptake of solid particulates, and Pinocytosis (cell drinking): uptake of fluid. Orally administered Sabin polio vaccine and large protein molecules are thought to be absorbed by pinocytosis. FACTORS INFLUENCING GI ABSORPTION AND BIOAVAILABILITY OF A DRUG FROM ITS DOSAGE FORM Absorption is the movement of drug from its site of administration into the circulation. Not only the fraction of the administered dose that gets absorbed, but also the rate of absorption is important. Except when given i.v., the drug has to cross biological membranes; absorption is governed by the above described principles. Other factors affecting absorption are: Aqueous solubility: Drugs given in solid form must dissolve in the aqueous biophase before they are absorbed; for poorly water soluble drugs (aspirin, griseofulvin) rate of dissolution governs rate of absorption. Obviously, a drug given as watery solution is absorbed faster than when the same is given in solid form or as oily solution. Concentration: Passive transport depends on concentration gradient; drug given as concentrated solution is absorbed faster than from dilute solution. Area of absorbing surface: Larger it is faster is the absorption.
17 Vascularity: of the absorbing surface Blood circulation removes the drug from the site of absorption and maintains concentration gradient across the membrane. Increased blood flow hastens drug absorption. Route of administration: This affects drug absorption, as each route has its own peculiarities. Factors affecting the absorption from the oral route I. Physicochemical Properties of Drug Substances Drug solubility and dissolution rate Particle size and effective surface area Polymorphism and amorphism Pseudopolymorphism (hydrates/solvates) Salt form of the drug Lipophilicity of the drug & pKa of the drug and pH II PATIENT RELATED FACTORS: Age Gastric emptying time Intestinal transit time Gastrointestinal pH Disease states Blood flow through the GIT Gastrointestinal contents: Other drugs Food Fluids Other normal GI contents III. Presystemic metabolism by: Lumenal enzymes Gut wall enzymes Bacterial enzymes Hepatic enzymes PHYSICOCHEMCAL FACTORS Drug Solubility and Dissolution Rate Consider the events that occur following oral administration of a solid dosage form , two critical slower rate-determining processes in the absorption of orally administered drugs are: General pharmacology
18
I. Rate of dissolution, and 2. Rate of drug permeation through the biomembrane. Dissolution is the RDS for hydrophobic, poorly aqueous soluble drugs like griseofulvin and spironolactone; absorption of such drugs is often said to be dissolution rate-limited. If the drug is hydrophilic with high aqueous solubilityfor example, cromolyn sodium or neomycin, then dissolution is rapid and the RDS in the absorption of such drugs is rate of permeation through the biomembrane. In other words, absorption of such drugs is said to be permeation rate limited or transmembrane rate-limited Particle Size and Effective Surface Area of the Drug Particle size and surface area of a solid drug are inversely related to each other. Smaller the drug particle, greater the surface area. Two types of surface area of interest can be defined: Absolute surface area which is the total area of solid surface of any particle, and Effective surface area which is the area of solid surface exposed to the dissolution medium. Greater the absolute and effective surface area greater will be the absorption Polymorphism and amorphism Polymorphism is the ability of a solid material to exist in more than one form or crystal structure and if the polymorphic form Is more stable it will be less soluble and hence less absorbed. An amorphism is a material that lacks long range crystalline order at the molecular level hence more soluble and more absorbed Hydrates/Solvates (Pseudopolymorphism) Generally, the anhydrous form of a drug has greater aqueous solubility than the hydrates. The anhydrous form of theophylline and ampicillin have higher aqueous solubilities, dissolve at a faster rate and show better bioavailability in comparison to their monohydrate and trihydrate forms respectively. On the other hand, the organic (nonaqueous) solvates have greater aqueous solubility than the nonsolvatesfor example, the n-pentanol solvate of fludrocortisone and
19 succinylsulfathiazole and the chloroform solvate of griseofulvin are more water-soluble than their nonsolvated forms.
20 Salt Form of the Drug Most drugs are either weak acids or weak bases. To enhance the solubility and dissolution rate of such drugs is to convert them into their salt forms Drug pKa, and Lipophilicity The pH partition theory (Brodie et al.) explains in simple terms, the process of drug absorption from the GIT and its distribution across all biologic membranes. The theory states that for drug compounds of molecular weight greater than 100, which are primarily transported across the biomembrane by passive diffusion, the process of absorption is governed by: The dissociation constant (pKa) of the drug. The lipid solubility of the unionized drug (o/w partition coefficient) The pH at the absorption site. Since most drugs are weak electrolytes (weak acids or weak bases), their degree of ionization depends upon the pH of the biological fluid. If the pH on either side on the membrane is different, then the compartment whose pH favors greater ionization of the drug will contain greater amount of drug, and only the unionized or undissociated fraction of drug, if sufficiently lipid soluble, can permeate the membrane passively until the concentration of unionized drug, on either side of the membrane becomes equal i.e. until equilibrium is attained. The above statement of the hypothesis was based on the assumptions that: The GIT is a simple lipoidal barrier to the transport of drug. Larger the fraction of unionized drug, faster the absorption. Greater the lipophilicity of the unionized drug, better the absorption.
21 I. Very weak acids (pKa > 8) such as phenytoin, ethosuximide and several barbiturates are essentially unionized at all pH values and therefore their absorption is rapid and independent of GI pH. 2. Acids in the pK, range 2.5 to 7.5 are greatly affected by changes in pH and therefore their absorption is pH-dependent; e.g. several NSAIDs like aspirin, ibuprofen, phenylbutazone, and a number of penicillin analogs. Such drugs are better absorbed from acidic conditions of stomach (pH < pKa ) where they largely exist in unionized form. 3. Stronger acids with pK a < 2.5 such as cromolyn sodium are ionized in the entire pH range of GIT and therefore remain poorly absorbed. Basic Drugs: Very weak bases (pKa < 5.0) such as caffeine, theophylline and a number of benzodiazepines like diazepam, oxazepam and nitrazepam are essentially unionized at all pH values and therefore their absorption is rapid and pH-independent. Bases in the pKa range 5 to 11.0 are greatly affected by changes in pH and hence their absorption is pH-dependent; e.g. several morphine analogs, chloroquine, imipramine and arnitriptyline. Such drugs are better absorbed from the relatively alkaline conditions of the intestine where they largely exist in unionized form. Stronger bases with pKa > 11.0 like mecamylamine and guanethidine are ionized in the entire pH range of GIT and therefore poorly absorbed. Patient related factors Age In infants, the gastric pH is high and intestinal surface and blood flow to the GIT is low resuting in altered absorption pattern in comparison to adults. In elderly persons, causes of impaired drug absorption include altered gastric emptying, decreased intestinal surface area and GI blood flow,
22 Gastric Emptying Ap art f r om dis solution of a drug and its p ermeation th e biomembrane, the passage from stomach to the small intestine, called as gastric emptying, can also a rate limiting step in drug absorption because the major site of drug absorption is intestine. Thus, generally speaking, rapid gastric emptying increases bioavailability of a drug Rapid gastric emptying is advisable where: A rapid onset of action is desired e.g. sedatives D i s s o l v e s o n l y i n t h e i n t e s t i n e e . g . e n t e r i c . c o a t e d dosage forms The drugs are not stable in the gastric fluids e.g. penicillin G and erythromycin The drug is best absorbed from the distal part of the small intest i n e , e . g . v i t a m i n s For better drug dissolution and absorption, the gastric emptying can be promoted by taking the drug on empty stomach. Gastrointestinal pH A tremendous fold difference in the hydrogen ion concentration is observed between the gastric and colon fluids. The GI pH generally increases gradually as one moves down the stomach to the colon and rectum GI fluid pH influence drug absorption in several ways (refer Drug pKa, and Lipophilicity ) Disease States Several disease states can influence the rate and extent of drug absorption. The 3 major classes of disease states that can influence the bioavailability of drugs are: Gastrointestinal diseases, Cardiovascular diseases, and Hepatic diseases.
23 1. Gastrointestinal diseases: A number of pathologic conditions of GIT can influence changes in drug absorption pattern, namely: Altered GI motility : (discussed earlier) Gastrointestinal diseases and infections: The influence of achlorhydria (decreased gastric acid secretion and increased stomach pH) on gastric emptying and drug absorption, especially that of acidic drugs (decreased absorption, e.g. aspirin) has been studied. Two of the intestinal disorders related with malabsorption syndrome that influence drug availability are celiac disease (characterized by destruction of villi and microvilli) and Crohn's disease Conditions associated with Crohn's disease that can alter absorption pattern are altered gut wall microbial flora, decreased gut surface area and intestinal transit rate.-Gastrointestinal surgery: Gastrectomy can result in drug dumping in the intestine, osmotic diarrhea and reduced intestinal transit time. Intestinal surgery also influences drug absorption for predictable reasons. 2. Cardiovascular diseases: Several changes associated with congestive cardiac failure influence bioavailability of a drug viz. edema of the intestine, decreased blood flow to the GIT and gastric emptying rate and altered GI pH, secretions and microbial flora. 3. Hepatic diseases: Disorders such as hepatic cirrhosis influence bioavailability mainly of drugs that undergo considerable first-pass hepatic metabolism e.g. propranolol. Blood Flow to the GIT For drugs that have high permeation rates, e.g. highly lipid soluble drugs or drugs absorbed through pores, the GI perfusion rate could be a rate-limiting step in the absorption. This is not so in the case of drugs having poor permeability coefficient. Blood flow is also important for actively absorbed drugs since oxygen and energy is required for transportation. Gastrointestinal Contents A number of GI contents can influence drug absorption as discussed below: General pharmacology
24 1. Food-drug interactions: Presence of food may delay, reduce, increase or may not affect drug absorption.(eg: presence of food delays the absorption of paracetamol while decreases that of tetracycline and increases that of diazepam and may not affect methyl dopa). Grapefruit juice and grapefruit in general, is a potent inhibitor of the cytochrome P450 CYP3A4 enzyme, which can impact the metabolism of a variety of drugs, increasing their bioavailability. In some cases, this can lead to a fatal interaction with drugs like astemizole or terfenadine. ThespecificmealcomponentsalsohaveaAs a general rule, drugs are better absorbed under fasting conditions, presence of food restarts & or prevents it. Delayed gastric emptying, affecting drugs unstable in the stomach e.g. penicillins, or preventing the transit of enteric coated tablets into the intestine which may be as long as 6 to 8 hours Formation of a poorly soluble, unabsorbable complex e.g. tetracycline-calcium Increased viscosity due to food thereby preventing drug dissolution and/or diffusion towards the absorption site Increased drug absorption following a meal could be due to one of the under mentioned reasons: Increased time for dissolution of a poorly soluble drug Enhanced solubility due to GI secretions like bile Prolonged residence time and absorption site contact of the drug e.g water soluble vitamins Interaction of drug with normal GI constituents: The GIT since a number of normal constituents such as mucin, bile salts can affect absorption of drugs. Eg: mucin a mucopolysaccharide of GI mucosa interacts and retards the absorption of drugs like streptomycin and other quaternary ammonium compounds. Bile salts increases the absorption of lipid soluble drugs (vit. ADEK) while decreases absorption of water soluble drugs (water soluble vitamins like vit B complex)
25 Drug drug interaction Drug interaction is the modification of the action of one drug by another Drug interaction is important, because whereas judicious use of more than one drug at a time can greatly benefit patients, adverse interactions are not uncommon, may be catastrophic, yet are often avoidable. Drug drug interactions affecting absorption and BA are Adsorption: adsoption of one drug by the other administered concomitantly eg : adsorbents in antidarrhoel preparation like kaolin /pectin Complexation: drugs can form complex with other drugs for example formation of a poorly soluble, unabsorbable chelate formation of tetracycline with metal ions present in preparations like antacids reducing the absorption of tetracycline pH change induced by drugs like antacids can affect the Decrease GI transit caused by drugs like absorption of other drugs affected by pH like penicillin G preparations whose absorption increases by increasing pH since it is acid labile. anticholinergics can promote the absorption of drugs which are stable at gastric pH eg: ranitidine while can retards the absorption of drugs which are unstable at gastric pH eg: paracetamol, erythromycin while vice versa in case of drugs which hastens the GI transit Alteration of GI metabolism by drugs like broad spectrum antibiotics (amoxicillin) will destroy normal microbial flora resulting in increase BA and toxicity of drugs metabolized by microbial enzymes eg: digoxin, warfarin Pre systemic Metabolism/First-Pass Effects The metabolism and loss of drug during its transit from the site of administration to the systemic circulation is referred to us first-pass or presystemic metabolism The first-pass metabolism or presystemic metabolism is a phenomenon of drug metabolism whereby the concentration of a drug is greatly reduced before it reaches the systemic circulation. It is the fraction of lost drug during the process of absorption which is generally related to the liver and gut wall. Notable drugs that experience a significant first-pass effect are imipramine, morphine, propranolol, buprenorphine, diazepam, midazolam, demerol, cimetidine, and lidocaine.After a drug is swallowed, it is absorbed by the digestive system and enters the hepatic portal system. It is carried General pharmacology
26 through the portal vein into the liver before it reaches the rest of the body. The liver metabolizes many drugs, sometimes to such an extent that only a small amount of
27 active drug emerges from the liver to the rest of the circulatory system. This first pass through the liver thus greatly reduces the bioavailability of the drug. Alternative routes of administration like suppository, intravenous, intramuscular, inhalational aerosol and sublingual avoid the first-pass effect because they allow drugs to be absorbed directly into the systemic circulation.. The 4 primary systems which affect presystemic metabolism of are Lumenal enzymes, Gut wall enzymes/mucosal enzymes, Bacterial enzymes Hepatic enzymes. Lumenal enzymes : These are the enzymes present in GIT and include enzymes from intestinal and pancreatic secretions. They contain hydrolases which hydrolyze ester drugs eg: chloramphenicol palmitate , peptidase which inactivate protein/polypeptide drugs eg Insulin. Gut wall enzymes : Also called as mucosal enzymes, they are present in stomach, intestine and colon. Alcohol dehydrogenase is an enzyme of stomach mucosa that inactivates ethanol Intestinal mucosa contains both phase I and phase II (predominant) enzymes, e.g. sulfation and inactivation of ethinyl estradiol. The colonic mucosa, also contain phase I and phase 11 enzymes. However, it is only the enzymes of proximal small intestine that are most active. Cytochrome P450 enzyme, CYP3A, that is present in the liver and responsible for the hepatic metabolism of many drugs, is present in the intestinal mucosa and that intestinal metabolism may be important for substrates of this enzyme e.g. cyclosporin
Bacterial enzymes: The GI microflora is scantily present instomach and small intestine and is rich in colon. Hence, most orally administered drugs remain unaffected by them. The colonic microbes generally render a drug more active or toxic on biotransformation. eg:sulfasalazine, a drug used in ulcerative colitis, is hydrolyzed to sulfapyridine(SP) and 5amino salicylic acid(5-AMS) by the microbial enzymes of the intestine and 5-AMS is responsible for local effect but SP is absorbed systemically and cause side effect like General pharmacology
28 hemolysis but useful in rheumatoid arthritis. An important role of intestinal microflora is that in enterohepatic cycling. Their enzymes hydrolyze the conjugates of drugs actively secreted via bile such as glucuronides of oral contraceptives. The free drugs are reabsorbed into the systemic circulation and increase the duration of action Hepatic enzymes: Several drugs undergo first-pass hepatic metabolism, the highly extracted ones being isoprenaline, propranolol, alprenolol, pentoxifylline, nitroglycerine, diltiazem, nifedipine, lidocaine, morphine, etc. Significance Oral dose is considerably higher than the sublingual or of parenteral dose eg: for angina pectoris isosorbide dinitrate oral dose is 20-40 mg while sublingual is 2.5-5 mg. Marked individual variations in the oral dose due the difference in the extent of presystemic metabolism High presystemic metabolism decreases the oral BA eg propranolol Since the liver is the major organ of presystemic metabolism the diseases of liver like cirrhosis will affect the orall BA of the drugs which undergo significant presystemic metabolism The combine drug administration / co administration of drug which either induce or inhibit hepatic enzymes can affect the BA of the other The first pass effect can also be exploited for a beneficial effect. Some prodrugs, for example codeine (methylmorphine, inactive) are converted from an inactive form to the pharmacologically active form (morphine proper) by first pass metabolism (in this case, demethylation).enalapril (ACE inh) to enalprilate.
29 ABSORPTION OF DRUGS FROM NON PER OS EXTRAVASCULAR ROUTES Drug absorption from all extra vascular sites is governed same factors that influence absorption from GIT viz. the physicochemical properties of drug, formulation factors, and anatomical, physiological and pathological characteristics of the patient. This is so because the barrier to transport of drugs into the systemic circulation from all such sites is a lipoidal membrane similar to the GI barrier and the major mechanism in the absorption is passive diffusion. One of the major advantages of administering drugs by noninvasive transmucosal routes such as nasal, buccal, rectal, etc. is that greater systemic availability Various transmucosal noninvasive routes of drug administration to bypass presystemic elimination in GIT/liver peptide and protein drugs can also be delivered by such routes. Some of the more important biopharmaceutic and pharmacokinetic principles that must be considered for non oral absorption is discussed here. Buccal/Sublingual Administration The two sites for oral mucosal delivery of drugs are: Sublingual route : The drug is placed under the tongue and allowed to dissolve Buccal route: The medicament is placed -between the cheek and the. gum The barrier to drug absorption from these routes is the epithelium of oral mucosa. Passive diffusion is the major mechanism for absorption of most drugs. Nutrients may be absorbed by carrier-mediated processes. Advantages of these routes are: Rapid absorption and higher blood levels due to high vascularization of the region and therefore particularly useful for administration of antianginal drugs No first-pass hepatic metabolism No degradation of drugs such as that encountered in the GIT. Presence of saliva facilitates both drug dissolution and its subsequent permeation by keeping the oral mucosa moist.
30 Notable factors to be considered in the oral mucosal delivery of drugs are: Lipophilicity of drug: Slightly higher lipid. solubility than that required for G1 absorption is necessary for passive permeation. Salivary secretion: In addition to high lipid solubility, the drug should be soluble in aqueous buccal fluids i.e. biphasic solubility of drug is necessary for absorption; absorption is delayed if the mouth is dry. pH of the saliva : Usually around 6, the buccal pH favors absorption of drugs which remain unionized. Binding to oral mucosa: Systemic availability of drugs that bind to oral mucosa is poor. Storage compartment: For some drugs such as buprenorphine, a storage compartment in the buccal mucosa appears to exist which is responsible for the slow absorption of drugs. Thickness of oral epithelium: Sublingual absorption is faster than buccal since the epithelium of former region is thinner and immersed in a larger volume of saliva. Factors that limit drug administration by these routes are: limited mucosal surface area (thus only a small dose can be administered), concern for taste of the medicament and discomfort (since the region is highly innervated). Examples of drugs administered by oral mucosal route include antianginals like organic nitrites, antihypertensives like nifedipine, analgesics like morphine and bronchodilators like fenoterol. Certain steroids like estradiol and peptides like oxytocin can also be administered. Apart from tablets, the drugs may be administered as a buccal spray" especially to children.
31
Rectal Administration Despite its diminished popularity, the rectal route of drug administration is still an important route for children and old patients. Drugs may be administered as solutions (microenemas) or suppositories. Absorption is more rapid from solutions than from suppositories but is more variable in comparison to oral route. Irritating suppository bases such as PEG promotes defecation and drug loss. Presence of fecal matter retards drug absorption. Though highly vascularized, absorption is slower because of limited surface area. The pH of rectal fluids (around 8) also influences drug absorption according to pH-partition hypothesis. Absorption of drugs from the lower half of rectum bypasses presystemic hepatic metabolism. Drugs administered by this route include aspirin, paracetamol, theophylline, few barbiturates, etc. Topical Administration Excluding the respiratory tract's contact with the inhaled air, the skin is virtually the sole human surface directly interfacing the body with the external environment. It is the largest organ of the body weighing approximately 2 Kg and 2 meter square in area and receives about 1/3rd of total blood circulating through the body. Though tolerant to many chemicals, topically contacted xenobiotics can evoke both local and systemic effects. When topically applied drugs are meant to exert their effects systemically, the mode of administration is called as percutaneous or transdermal delivery. . Several factors influence passive percutaneous absorption of drugs: Thickness of stratum corneum : absorption is very slow from regions such as foot and palm where the skin has thickened stratum corneum. Presence of hair follicles: absorption is rapid from regions where numerous hair follicles exist e.g. scalp. Trauma--cuts, rashes, inflammation, mild bums or other conditions, in which the stratum corneum is destroyed, promote drug absorption.
32 Hydration of skin: soaking the skin in water or occluding it by using emollients, plastic film or dressing, promote hydration of skin and drug absorption. Environment humidity and temperature: higher humidity and temperature increase both the rate of hydration as well as local blood flow and hence drug absorption. Age: gross histological changes take place as the skin ages. Aged skin is more prone to allergic and irritant effects of topically contacted chemicals as a result of hardening of blood vessels. Infants absorb drug through skin as efficiently as adults. Their ratio of surface area to body weight is 3 times that of adults; hence, systemic toxicity of topically applied drugs is of particular concern in infants. Grooming: the frequency and vigor with which one bathes and the type of soap that is used also contribute to variability in drug absorption. Exposure to chemicals: occupational exposure to solvents can accelerate shedding of epidermal cells and enhance drug absorption. Vehicle or base: the vehicle in which the drug is incorporated influences drug absorption; the one in which the drug is dissolved rather than dispersed promotes absorption. Permeation enhancers: incorporation of certain chemicals such as DMSO, propylene glycol, etc. in the topical formulations aid drug penetration. Chronic use of certain drugs: long term use of cortisol or keratolytics like salicylic acid results in enhanced drug penetration. Drugs that are administered percutaneously include nitroglycerine, lidocaine, betamethasone, estradiol, testosterone, etc. The route is particularly useful for drugs with low oral availability and short duration of action; the effect of the latter category of drugs is prolonged because percutaneous absorption is a slow process. Intraocular Administration
33 Topical application of drugs to the eyes is mainly meant for local effects such as mydriasis, miosis, anesthesia or treatment of infections, glaucoma, etc. The barrier to intraocular penetration of drugs is the cornea which possesses both hydrophilic and lipophilic
34 characteristics. Thus, for optimum intraocular permeation, drugs should possess biphasic solubility. The pH of lacrimal fluid influences absorption of weak electrolytes such as pilocarpine while, pH of the formulation influences lacrimal outputhigher pH decreases tear flow and promotes drug absorption whereas lower pH solutions increase lacrimation and subsequent drug loss due to drainage. Rate of blinking also influences drainage loss. The volume of fluid instilled into the eyes also affects bioavailability and effectiveness of the drug. Normally, the human eye can hold around 10 ml of fluids; hence, instillation of small volume of drug solution in concentrated form increases its effectiveness than when administered in large volume in dilute form. Viscosity imparters in the formulation increase bioavailability by prolonging drug's contact time with the eye. Oily solutions, ointments and gels show sustained drug action for the same reason. Sometimes systemic absorption of a drug with low therapeutic index such as timolol may precipitate undesirable toxic effects. Systemic entry of drugs occur by way of absorption into lacrimal duct which drains lacrimal fluid into the nasal cavity and finally into the GIT. This can be prevented by simple eyelid closure or nasolacrimal occlusion by pressing the finger tip to the inside corner of the eye after drug instillation. Vaginal Administration Drugs meant for intravaginal application are generally intended to act locally in the treatment of bacterial or fungal infections or prevent conception. The route is now used for systemic delivery of contraceptives and other steroids, without the disadvantage of first-pass metabolism. Controlled delivery and termination of drug action when desired, is possible with this route. Factors that may influence drug absorption from intravaginal site include pH of lumen fluids (4 to 5), vaginal secretions and the microorganisms present in the vaginal lumen which may metabolize the drug.
35
BIOAVAILABILITY is defined as per U.S. and Drugs Administration as "the rate at and the extent to which the active form of the drug is available at the desired site for action (or practically speaking in the blood) BIOAVAILABILITY is an ABSOLUTE TERM which requires measurement of both the true rate and total amount (extent) of drug that reaches the general circulation from an administered dosage form. Absolute bioavailability: when the systemic availability of the drug administered orally is determined in comparison to its i.v. administration. Relative bioavailability: when the systemic availability of the drug administered orally is compared with that of an oral standard of the same drug. MEASUREMENT OF BIOAVAILABILITY Absolute bioavailability of a pharmacological substance or the drug product is actually defined as the measure or the assessment obtained by comparison between the respective bioavailability after oral and the intravenous bolus injection of the drug product. This measurement is acceptable and valid as long as the elimination rate and the volume of distribution of the drug material are independent of route of administration of the very dosage form. The absolute bioavailability of a given drug using the plasma concentration-time curves are obtained following the administration of equivalent doses of the drugs through an absorption site and through the intravenous route on the same subjects i.e. On the same patient at distinct occasions. Typical plasma concentration time curves obtained by administration of the equivalent doses of the same drug substance by the intravenous route (bolus injection) of administration and the extra venous route that is oral administration are shown in figure below:
36
Plasma drug conc. (g/ml
IV Bolus
Oral
Time (hrs) Plasma drug level vs curves following IV bolus and Oral administration
The given plots are useful to obtain the data shown below:
[AUC] oral/ (Dose)oral Absolute bioavailability = [AUC]iv/(Dose)iv
Relative bioavailability: It has been defined as the ratio of bioavailability of a drug product and that of a recognized standard. In general, a recognized standard is either a branded or marketed drug product or a standard dosage form acceptable by the Food and Drug by Administration. Thus recognized standard must have the desired safety, purity, efficacy, identity, strength that it purports to possess. The bioavailability of a test formulation is compared to the availibity of the drug in a selected dosage form using a crossover study Relative bioavailability = [AUC] test/ (Dose) test [AUC] standard/ (Dose) standard.
37 Percent relative bioavailibity can be easily obtained by multiplying this fraction with 100. Percent bioavailability can be calculated from the urinary drug excretions data, provided the condition that unchanged drug is excreted in the urine. EQUIVALENCE is a RELATIVE TERM which means a comparison of one brand product with another of the same drug with a set of established standards. could be compared in several ways: BIOEQUIVALENCE If two or more similar dosage forms of the same drug reach the blood circulation at the same relative rate and to the same relative extent, these are called bioequivalent preparations of the generic drug In other words the two similar dosa g e f o rm s of o n e d r u g c a n b e c a l l ed bioequivalent if their plasma level profiles are comparable and super imposable within prescribed limits. For example, two brand preparations of phenytoin like Dilantin (Park Davis) and Eptoin (Boots) may or may not be bioequivalent. Differences of less than 25% in Bioavaila-bility among several formulations of one drug will usually have no significant effect on clinical outcome; hence such formulations can be called as bioequivalent. Thus measurements of bioavailability are immaterial for drugs having higher margin of safety, e.g. with water soluble vitamins, antacids and some antimicrobials having large therapeutic index. But the differences in Bioavailabili(y assume a much grealer con-tern with drugs that show a steep doseresponse relationship, i.e. with drugs which obey zero order or mixed order elimination kinetics (e.g. phenytoin, warfarin and other oral anticoagulants, digoxin, phenylbutazone and aspirin in high doses) and with drugs having a narrow margin of safety Equivalence
38 (e.g. antiarrhythmics, antidiabetics, adrenal steroids, chloramphenicol, tetracycline and theophylline). in such cases, the patient should be stabilised with one brand formulation only and that brand should never be changed (unless the changed brand is bioequivalent to the one that was being used). Because, if a patient who is stabilised on one brand product is switched over to another brand of the same drug, there could be either a therapeutic failure (due to decreased bioavailability) or drug intoxication (due to increased bioavailability). CLINICAL EQUIVALENCE The two brand products of one drug can be called as clinically equivalent if they provide an "identical in vivo pharmacological response" as measured by control of symptoms or a disease. For example, Dilantoin and Eptoin may or may not be bioequivalent but may be clinically equivalent if both provide same pharmacological response qualitatively. THERAPEUTIC EQUIVALENCE If one structurally deferent drug can provide the same therapeutic response or clinical response as with another drug, these are then called therapeutically equivalent drugs. For example, trifluperazine (belonging to phenothiazine group) may be therapeutic equivalent to haloperidol (belonging to butyrophenone group) if both provides equivalent therapeutic results in the treatment of schizophrenia. CHEMICAL EQUIVALENCE If two or more dosage forms of the same drug contain the same labeled quantities of the drug as specified in pharmacopoeia, these are called as chemically equivalent drugs. For example, dilantoin and Eptoin may be chemically equivalent if they contain same quantity of phenytoin on chemical assay.
39 Chapter V DISTRIBUTION OF DRUGS Drug distribution means the reversible transfer of drug from one location to another within the body ie reversible transfer of a drug between the blood and extra vascular tissue Once a drug has entered the vascular system it becomes distributed throughout the various tissues and body fluids in a pattern that reflects the physiochemical nature of the drug and the ease with which it penetrates different membranes. As the Pharmacological action of a drug depends upon its concentration at the site of action Distribution plays a significant role in the Onset, Intensity, and Duration of Action.Distribution of a drug is not Uniform throughout the body because different tissues receive the drug from plasma at different rates and to different extents. Drug distribution patterns Distribution can be thought of as following one of four types of patterns: The drug may remain largely within the vascular system. Plasma substitutes such as dextran are an example of this type, but drugs which are strongly bound to plasma protein may also approach this pattern. Some low molecular weight water soluble compounds such as ethanol and a few sulfonamides become uniformly distributed throughout the body water. A few drugs are concentrated specifically in one or more tissues that may or may not be the site of action. Iodine is concentrated by the thyroid gland. The antimalarial drug chloroquine may be present in the liver at concentrations 1000 times those present in plasma. Tetracycline is almost irreversibly bound to bone and developing teeth. Consequently tetracyclines should only be given to young children or infants in extreme conditions as it can cause discoloration and mottling of the developing second set of teeth. Another type of specific concentration may occur with highly lipid soluble compounds which distribute into fat tissue (thiopental).
40 Most drugs exhibit a non-uniform distribution in the body with variations that are largely determined by the ability to pass through membranes and their lipid/water solubility. The highest concentrations are often present in the kidney, liver, and intestine usually reflecting the amount of drug being excreted. Pattern 4 is the most common being a combination of patterns 1, 2 and 3.
Apparent volume of distribution (Vd) is a useful indicator of the type of pattern that characterizes a particular drug Apparent volume of distribution (Vd) it is the hypothetical volume of body fluids in to which the drug is dissolved or distributed
Dose administered by IV route Apparent volume of distribution (Vd) = Plasma concentration
41 Representing Various Volumes Distribution Patterns Apparent Volumes of Distribution Drug Chloroquine Nortriptyline Digoxin Lidocaine Theophylline Tolbutamide Liter/Kg 94 20 6.3 1.5 0.45 0.12 Liter/70 Kg 6600 1400 440 110 32 8.4
A value of Vd in the region of 3-5 liter (in an adult) would be compatible with pattern 1. This is approximately the volume of plasma. Pattern two would be expected to produce a Vd value of 30 to 50 liter, corresponding to total body water. Agents or drugs exhibiting pattern 3 would exhibit very large values of Vd if the drug concentration effect was acting on most of the dose. Chloroquine has a Vd value of approximately 17,000 liter. Drugs following pattern 4 may have a Vd value within a wide range of values. These patterns of variation have been used to determine body fluid volumes. FACTOR AFFECTING DRUG DISTRIBUTION 1. Tissue permeability of drugs a)Physicochemical properties of the drugs b)Physiological barriers to diffusion of drugs 2. 3. 4. 5. 6. Organ/tissue size and perfusion rate Binding of drugs to tissue components Binding of drug to tissue components Binding of drug to extra vascular tissue protein Miscellaneous Age, pregnancy, obesity, diet, disease state, drug interaction.
42 1. Tissue permeability of drugs: For any drugs to be absorbed in systemic circulation exept those administered by iv route they has to pass through biological membranes hence the ability of the drug to penetrate tissue governs the BA of the drugs and it deprnds on the following a) Physicochemical properties of the drugs In the absorption section, we have already covered some material about membrane permeability. The capillaries are typically lined with endothelium whose cells overlap, though to a lesser degree than epithelial cells. Also, the junctions between cells are discontinuous. Capillary walls are quite permeable. Lipid soluble drugs pass through very rapidly. Water soluble compounds penetrate more slowly at a rate more dependent on their size. Low molecular weight drugs pass through by simple diffusion. For compounds with molecular diameter above 100 transfer is slow. For drugs which can be ionized the drug's pKa and the pH of the blood will have a large effect on the transfer rate across the capillary membrane. There are two deviations to the typical capillary structure which result in variation from normal drug tissue permeability. b) Physiological Barriers to Distribution of Drugs A membrane (or a barrier) with special structural features can be a permeability restriction to distribution of drugs to some tissues. Some of the important -simple and specialized physiologic barriers are: 1. 2. 3. 4. 5. 6. Simple capillary endothelia barrier Simple celfmembrane barrier Blood-brain barrier Cerebrospinal fluid barrier Placental barrier Blood-testis barrier The Simple Capillary Endothelial Barrier The membrane of capillaries that supply blood to most tissues is, practically speaking, not a barrier to moieties which we call drugs. Thus, all drugs, ionized or unionized, with a molecular size less than 600 daltons diffuse through the capillary endothelium and into the interstitial fluid. Only drugs bound to the blood components are restricted because of the large molecular size of the complex. General pharmacology
43 The Simple Cell Membrane Barrier: Once a drug diffuses from the capillary wall into the extracellular fluid, its further entry into cells of most tissues is limited by its permeability through the membrane that lines such cells. Such a simple cell membrane is similar to the lipoidal barrier in the GI absorption of drugs (discussed earlier Blood-Brain Barrier (BBB): Is a separation of circulating blood and the brain extracellular fluid (BECF) in the central nervous system (CNS). It occurs along all capillaries and consists of tight junctions around the capillaries that do not exist in normal circulation. Endothelial cells restrict the diffusion of microscopic objects (e.g. bacteria) and large or hydrophilic molecules into the cerebrospinal fluid (CSF), while allowing the diffusion of small hydrophobic molecules (O2, hormones, CO2). Cells of the barrier actively transport metabolic products such as glucose across the barrier with specific proteins. At the interface between blood and the brain, endothelial cells are stitched together by these tight junctions, which are composed of smaller subunits, frequently biochemical dimers, that are transmembrane proteins such as occludin, claudins, junctional adhesion molecule (JAM. Moreover, the presence of special cells called as astrosytes, . (Astrocyte cell projections called astrocytic feet also known as "glia limitans") which are the elements of the supporting tissue found at the base of endothelial membrane, form a solid envelope around the brain capillaries. As a result, the intercellular passage is blocked and for a drug to gain access from the capillary circulation into the brain, it has to pass through the cells rather than between them (intracellularly).
44
However, there are specific sites in the brain where the BBB does not exist, namely, the chemoreceptor trigger zone and the median hypothalamic eminence. Moreover, drugs administered Intranasally may diffuse directly into the CNS because of the submucosal areas of the nose and the subarachnoid space of the olfactorylobe. Since the BBB is a lipoidal barrier, it allows only the drugs having high oil water partition coefficient to diffuse passively whereas moderately lipid soluble and partially ionized molecules penetrate at a slow rate. The effective partition coefficient of thiopental, a highly lipid soluble drug is 50 times that of pentobarbital and crosses the-BBB much more rapidly. Polar natural substances such as sugars and amino acids are transported to brain actively. Thus, structurally similar foreign molecules can also penetrate the BBB by the same mechanism. Most antibiotics such as penicillins which are polar, water-soluble and ionized at plasma pH, do not cross the BBB under normal circumstances. General pharmacology
45
46 The selective permeability of lipid soluble moieties through the, BBB makes appropriate choice of a drug to treat CNS disorders an essential part of therapy; for example, Parkinsonism, a disease characterized by depletion of dopamine in the brain, cannot be treated by administration of dopamine as it does not cross the BBB. Hence, levodopa, which can penetrate the CNS where it is metabolized to dopamine, is used in its treatment. Targeting of polar drugs to brain in certain conditions such as tumor had always been a problem. Meningitis is an inflammation of the membranes that surround the brain and spinal cord (these membranes are known as meninges). Meningitis is most commonly caused by infections with various pathogens, examples of which are Streptococcus pneumoniae and Haemophilus influenzae. When the meninges are inflamed, the bloodbrain barrier may be disrupted. This disruption may increase the penetration of various substances (including either toxins or antibiotics) into the brain. Treatment with third-generation or fourth-generation cephalosporin is usually preferred. Three different approaches have been utilized successfully to promote crossing the BBB by drugs: Use of permeation enhancers such as dimethyl sulfoxide (DMSO) Osmotic disruption of the BBB by infusing internal carotid artery with mannitol Use of dihydropyridine like carriers In the latter case, the lipid soluble dihydropyridine is linked as a carrier to the polar drug to form a prodrug that readily crosses the BBB. In the brain, the CNS enzymes oxidize the dihydropyridine moiety to the polar pyridinium ion form that cannot diffuse back out of the brain. As a result, the drug gets trapped in the CNS. Such a redox system has been used to deliver steroidal drugs to the brain.
47 Blood-Cerebrospinal Fluid Barrier is formed mainly by the choroid plexus of the lateral, third and fourth ventricles and is similar in composition to the ECF of brain. The capillary endothelium that lines the choroid plexus has open junctions or gaps and drugs can flow freely into the extracellular space between the, capillary wall and the choroidal cells. However, the choroidal cells are joined to each other by tight junctions forming the blood-CSF barrier which has permeability characteristics similar to that of the BBB. Highly lipid soluble drugs can cross the blood-CSF barrier with relative ease whereas moderately lipid soluble and partially ionized drugs permeate slowly. A drug that enters the CSF slowly cannot achieve a high concentration as the bulk flow of CSF continuously removes the drug. For any given drug, its concentration in the brain will always be higher than in the CSF. Placental Barrier: The maternal and the fetal blood vessels are separated by a number of tissue layers m made of fetal trophoblast basement membrane and the endothelium which together constitute the placental barrier. The human placental barrier has a mean thickness of 25 microns in early pregnancy that reduces to 2 microns at full term which however does not reduce its effectiveness. Many drugs having molecular weight less than 1000 daltons and moderate to high lipid solubility e.g. ethanol, sulfonamides, barbiturates, gaseous anesthetics, steroids, narcotic analgesics, anticonvulsants and some antibiotics, cross the barrier by simple diffusion quite rapidly. This slows that the placental barrier is not as effective a barrier as BBB. Nutrients essential for the fetal growth are transported by carrier-mediated processes. Immunoglobulins are transported by endocytosis. Blood-Testis Barrier : This barrier is located not at the capillary endothelium level but at sertoli-sertoli cell junction. It is the tight junctions between the neighboring sertoli cells that act as the blood-testis barrier. This barrier restricts the passage of drugs to spermatocytes and spermatids.
48 2. ORGAN/TISSUE SIZE AND PERFUSION RATE Distribution is permeability rate-limited in the following cases: When the drug under consideration is ionic, polar or water soluble Where the highly selective physiologic barriers restrict the diffusion of such drugs to the inside of the cell In contrast, distribution will be perfusion rate-limited when: The drug is highly lipophilic The membrane across which the drug is supposed to diffuse is highly permeable such as those of the capillaries and the muscles. Whereas only highly lipophilic drugs such as thiopental can cross the most selective of the barriers like the BBB, highly permeable capillary wall permits passage of almost all drugs (except those bound to plasma I proteins). In both circumstances, the rite-limiting step is the rate of blood flow or perfusion to the tissue. Greater the blood flow, faster the distribution. Perfusion rate is defined as the volume of blood that flows/ unit time/ unit volume of the tissue and unit is ml/min/ml of tissue . Highly perfused tissues such as lungs, kidneys,adrenal, liver, heart and brain are rapidly equilibrated with lipid soluble drugs. moderately per fused are muscles and skin and poorly perfused are fat (adipose tissue) and bones
49 The extent to which a drug is distributed in a particular tissue or organ depends upon the size of the tissue i.e. tissue volume) and the tissue/blood partition coefficient of the drug. Consider the classic example of thiopental.This lipophilic drug has a high tissue/blood partition coefficient towards the brain and still higher for adipose tissue. Since the brain (site of action) is a highly per fused organ, following iv injection, thiopental readily diffuses into the brain showing a rapid onset of action. Adipose tissue being poorly perfused, takes longer time to get distributed with the same drug. But as the concentration of thiopental in the adipose proceeds towards equilibrium, the drug rapidly diffuses out of the brain and localizes in the adipose tissue whose volume is more than 5 times that of brain and has greater affinity for the drug. The result is rapid termination of action of thiopental due to such tissue redistribution. 3.. BINDING OF DRUGS TO TISSUE COMPONENTS A drug in the body can bind to several components such as the plasma proteins, blood cells and hemoglobin (i.e. blood components) and extra vascular proteins and other tissues. Protein Binding of Drugs A drug in the body can interact with several tissue components of which the two major categories blood components and the extra vascular tissues. The interacting molecules are generally the macromolecules such as proteins, DNA or adipose. The proteins are particularly responsible for such an interaction. The phenomena of complex formation with proteins is called as protein binding of drugs. Binding of drugs generally involves weak chemical bonds such as hydrogen bonds, hydrophobic bonds, ionic bonds or van der Waal's forces and there fore is a reversible process. Irreversible drug binding, though rare, arises as a result of covalent binding and is often a reason for the carcinogenicity or tissue toxicity of the drug; for example, covalent binding of chloroform and paracetamol metabolites to liver results in hepatotoxicity. Binding of drugs falls into2 classes: 1. Binding of drugs to blood components like Plasma proteins General pharmacology
50
Blood cells
51 2. Binding of drugs-to extra vascular tissue proteins, fats, bones, etc. BINDING OF DRUGS TO BLOOD COMPONENTS Plasma Protein-Drug Binding it is the reversible binding of drugs to plasma proteins, the main interaction of drug in blood compartment the extent of binding of drugs to various plasma proteins are as per the following order albumin > 1-acid glycoprotein > lipoproteins > Binding of Drugs to Human Serum Albumin The human serum albumin (HSA), having a molecular weight of 65,000, is the most abundant-plasma protein with a large drug binding capacity. Both endogenous compounds and several compounds(drugs) with varying structure binds to albumin. Different sites on HSA have been identified for drug-binding They are: Site I : Also called as warfarin and azapropazone binding site, it represents the region to which large number of drugs are bound, e.g. several NSAIDs (phenylbutazone, naproxen, indomethacin), sulfonamides (sulfadimethoxine, sulfamethizole), phenytoin, sodium valproate and the endogenous compound bilirubin. Site II : It is also called as the diazepam binding site. Drugs which bind to this region include benzodiazepines, medium chain fatty acids, ibuprofen, ketoprofen, tryptophan, cloxacillin, probenicid, etc. Site I and site 11 are responsible for the binding of most drugs. Site III is also called as digitoxin binding site. Site IV is also called as tamoxifen binding site. Very few drugs bind to sites III and IV. A drug can bind to more than one site in which case the main binding site is called as the primary site and the other as the secondary site, for example site I is the primary site for
52 dicoumarol and site 11 the secondary site. Groups of drugs that bind to the same site compete with other for the same site, but drugs that bind to one site do not competitively inhibit binding of
53 drugs to other sites. However, they may either promote or retard binding of a drug to another site by energetic coupling mechanisms (allosteric effect) Binding of Drugs to 1Acid Glycoprotein (AGP) Also called as the orosomucoid, it has a molecular weight of 44,000 and a plasma concentration range of 0.04 to 0.1 g%. It binds to a number of basic drugs like imipramine, nortriptyline, lidocaine,propranolol, quinidine and disopyramide. Binding of Drugs to Lipoproteins Binding of drugs to HSA and AAG involve hydrophobic bonds. Since only lipophilic drugs can undergo hydrophobic bonding, lipoproteins can also bind to such drugs because of their lipid content. However, the plasma concentration of lipoproteins is much less in comparison to HSA and AAG. A drug that binds to lipoproteins does so by dissolving in the lipid core of the protein .and thus its capacity to bind depends on its lipid content. The molecular weight of lipoproteins varies from 2 lakhs to 3 lakhs depending on their chemical composition. They are classified on the basis of their density as Chylomicrons Very low density lipoproteins (VLDL) Low density lipoproteins (LDL) (predominant in humans) High density lipoproteins (HDL) The lipid core of these macromolecules consists of triglycerides and cholesteryl esters and the outside is made of apoproteins (free cholesterol and proteins). Predictably, VLDL is rich in triglycerides and HDL is rich in apoproteins. The binding of drugs to lipoproteins is noncompetitive. A number of acidic (diclofenac), neutral (cyclosporin A) and basic drugs (chlorpromazine), and Basic, lipophilic drugs have relatively more affinity General pharmacology
54 Binding of Drugs to Globulins Several plasma globulins have been identified and are labeled as 1-globulin : also called as transcortin or CBG (corticosteroid binding globulin.), it binds a number of steroidal drugs such as cortisone and prednisone. It also binds to thyroxine and cyanocobalamin. 2-globulin . also called as ceruloplasmin, it binds vitamins A, D, E and K, and cupric ions. 1globulin also called as transferrin, it binds to ferrous ions. 2globulin binds to carotinoids . -globulin : binds specifically to antigens. Binding of Drugs to Blood Cells More than 40% of the blood comprises of blood cells of which the major cell component is the RBC. The RBCs constitute 95% of the total blood cells. Thus, significant RBC drug binding is possible. The red cell is 500 times in diameter as the major plasma protein binding component, albumin. The RBC comprises of 3 components each of which can bind to drugs: Hemoglobin : It has a molecular weight of 64,500 (almost equal to that of HSA) but is 7 to 8 times the concentration of albumin in blood. Drugs like phenytoin, pentobarbital and phenothiazines bind to hemoglobin. Carbonic anhydrase: Drugs known to bind to it are acetazolamide and chlorthalidone (i.e. carbonic anhydrase inhibitors). Cell Membrane : Imipramine and chlorpromazine are reported to bind with the RBC membrane. It has been shown that the rate and extent of entry into RBC is more for lipophilic drugs, e.g. phenytoin. Hydrophilic drugs like ampicillin do not enter RBC.
55 TISSUE BINDING OF DRUGS (TISSUE LOCALIZATION OF DRUGS) A drug can bind to one or more of the several tissue components. Tissue-drug binding is important in distribution from two viewpoints: It increases apparent volume distribution of drugs in contrast plasma protein binding will decreases it; this is because plasma conc: of free drug The tissue binding results in localization of a drug at specific site in the body ( w i t h a subsequent increase in biological half-life). This is more so because a number of drugs tetrachloride and bromobenzene bind bind irreversibly with the tissues (contrast to plasma protein-drug binding); for example, oxidation products of paracetamol, phenacetin, chloroform, carbon covalently to hepatic tissues. Such tissue binding also results in specific organ toxicity of the drugs Tissue can act as a storage site for the tissue bound drugs. Drugs that bind to both tissue and plasma components results in competition between the binding sites. Factors influencing localization of drugs in tissues include lipophilicity and structural features of the drug, perfusion rate, pH differences etc. For majority of drugs that bind to extravascular tissues, the order of binding is: liver > kidney > lung > muscle. Liver : As stated earlier, epoxides of a number of halogenated hydrocarbons and paracetamol bind irreversibly to liver tissues resulting in hepatotoxicity. Lungs : Basic drugs like imipramine, chlorpromazine and antihistamines accumulate in lungs. Kidneys : Metallothionin, a protein present in kidneys, binds to heavy metals such as lead, mercury, and cadmium and results in their renal accumulation and toxicity. Skin : chloroquine and phenothiazines accumulate in skin by interacting with melanin. the parameter is related to the ratio of amount of drug in the body to
56 Eyes : The retinal pigments of the eye also contain melanin. Binding of chloroquine and phenothiazines to it is responsible for retinopathy. Hairs : Arsenicals, chloroquine and phenothiazines are reported, to deposit in hair shafts. Bones : Tetracycline is a well known example of a drug that binds to bones and teeth. Administration of this antibiotic to infants or children during odontogenesis results in permanent brown-yellow discoloration of teeth. Lead is known to replace calcium from bones and cause their brittleness. Fats : Lipophilic drugs such as thiopental and the pesticide DDT accumulate in adipose tissues. However, high o/w partition coefficient is not the only criteria for adipose distribution of drugs since several highly lipophilic (more than thiopental) basic drugs like imipramine and chlorpromazine are not localized in fats. The poor perfusion of adipose could be the reason for such an ambiguity. Reports have stated that adipose localization of drugs is a result of binding competition between adipose and non-adipose tissues (lean tissues like muscles, skin and viscera). Nucleic Acids : Molecular components of cells such as DNA interact strongly with drugs like chloroquine and quinacrine resulting in distortion of its double helical structure. SIGNIFICANCE OF PROTEIN/TISSUE BINDING OF DRUGS Since only free form of the drug is active and able to enter the site of action to produce the effect or get metabolized or excreted the PPB (plasma protein bound) drugs are phramacokinetically and pharmacodynamically inert. PPB drugs are largely restricted ton the vascular compartment and maintains an equilibrium between the free and bound drug ies as the free drug concentration decreases in plasma due to entry the site of action to produce the effect or get metabolized or excreted the drug is release from PPB to maintain the equilibrium.hence PPB act as a drug depot and increases the duration of action.
57 The absorption equilibrium is attained by transfer of free drug from the site of administration into the systemic circulation and when the concentration in these two compartments become equal. Following equilibrium, the process may stop. However, binding of the absorbed drug to plasma proteins decreases free drug concentration and disturbs such equilibrium. Thus, sink conditions and the concentration gradient are reestablished which now act as the driving force for further absorption. This is particularly useful in case of ionized drugs which are transported with difficulty. Water insoluble drugs, neutral endogenous macromolecules such as heparin and several steroids and oil soluble vitamins are circulated and distributed to tissues by binding especially to lipoproteins which act as a vehicle for such hydrophobic compounds. Plasma protein binding restricts the entry of drugs that have specific affinity for certain tissues. This prevents accumulation of a large fraction of drug in such tissues and thus, subsequent toxic reactions. Plasma protein-drug binding favors uniform distribution of drugs throughout the body by its buffer function (maintains equilibrium between the free and the bound drug). A protein bound drug in particular does not cross the BBB, the placental barrier PPB drugs are not filtered by glomerular filteration due to large size hence not easily excreted and also not metabolized since only free drug can enter the metabolizing organs resulting in increase biological half life. For example, tetracycline, which is only 65% bound, has an elimination half-life of 8.5 hours in comparison to 15.1 hours of doxycycline which is 93% bound to plasma proteins
58 Displacement Interactions and Toxicity When two or more drugs can bind to the same site, competition b e t w e e n t h e m f o r i n t e r a c t i o n w i t h t h e b i n d i n g s i t e r e s u l t s . I f o n e o f t h e drugs (drug A) is bound to such a site, then administration of another drug (drug B) having affinity for the same site results in displacement of drug A from its binding site. Such a drug-drug interaction for the common binding site is called as displacement interaction. The drug A here is called as the displaced drug and drug B as the displacer. Warfarin and phenylbutazone have same degree of affinity for HSA. Administration of phenylbutazone to a patient on warfarin therapy results in displacement of latter from its binding site. The free warfarin may cause adverse hemorrhagic reactions which may be lethal. Phenylbutazone is also known to displace sulfonamides from their HSA binding sites. Displacement interactions can result in unexpected rise in free concentration of the displaced drug which may enhance clinical respone or toxicity.Even a drug metabolite can affect displacement interaction. Clinically significant interactions will result when: The displaced drug (e.g. warfarin) Is more than 95% bound Has a small volume of distribution (less than 0.15 L/Kg) Shows a rapid onset of therapeutic or adverse effects Has a narrow therapeutic index (safety) The displacer drug (e.g. phenylbutazone) Has a high degree of affinity as the drug to be displaced Competes for the same binding sites The drug/protein conc: ration is high Show rapid and large increase in plasma drug conc: General pharmacology
59 Displacement interactions are significant in case of drugs which are more than 95% bound. A displacement of just 1% of a 99% bound drug results in doubling of the free drug concentration i.e. a 100% rise. For a drug that is bound to a lesser extent e.g. 90%, displacement of 1% results in only a 10% rise in free drug concentration which may be insignificant clinically. Interaction with normal endogenous substance and drug Kernicterus in infants is an example of a disorder caused by displacement of bilirubin from albumin binding sites by the NSAIDs. Since in infants the BBB is not intact and the level of enzyme glucuronyl tranferase is less for the conjugation of bilirubin with glucuronide and excrete it. Hence it cause the entry of bilirubin in to CNS causing encephalopathy and the condition is known as Kernicterus. Allosteric changes in protein molecule The binding of drug to the secondary site can affect the drugs binding to the primary site and such drugs are known as allosteric effector eg. Aspirin is an allosteric effector which increases the affinity of phenylbutazone to albumin while decreases that of flufenamic acid. Diagnosis The chlorine atom of chloroquine when replaced with radiolabeled I131 can be used to visualize melanomas of the eye since chloroquine has the tendency to interact with the retinal protein. The thyroid gland has greater affinity for iodine containing compounds, hence any disorder of the same can be detected by tagging such a compound with a radioisotope of iodine. Therapy and Drug Targeting The binding of drugs to lipoproteins can be used for site specific delivery of hydrophilic moieties. This is particularly useful in cancer chemotherapies since certain tumor cells have greater affinity for LDL than n o rm a l t i s s u es . Estradiol binds selectively and strongly to prostrate and thus prostrate cancer can be treated by attaching nitrogen mustard to estradiol for targeting of prostrate glands. Drug targeting prevents normal cells from getting destroyed.
60 FACTORS AFFECTING PROTEIN-DRUG BINDING Factors affecting protein-drug binding can be broadly categorized as1. Factors relating to the drug Physicochemical characteristics of the drug Concentration of drug in the body Affinity of a drug for a particular binding component 2. Factors relating to the protein and other binding components Physicochemical characteristics of the protein or binding agent Concentration of protein or binding component Number of binding sites on the binding agent 3. Drug interactions Competition between drugs for the binding site (displacement interactions) Competition between drugs and normal body constituents Allosteric changes in protein molecule 4. Patient related factors Age Intersubject variations Disease state
61 DRUG RELATED FACTORS Physicochemical Characteristics of the Drug As mentioned earlier, protein binding is directly related lipophilicity of drugs. An increase in lipophilicity increases the extent of binding; for example, the slow absorption of cloxacillin in comparison to ampicillin after i.m. injection is attributed to its higher lipophilicity and larger (95%) binding to proteins while the latter is less lipophilic and only 20% bound to proteins. Highly lipophilic drugs such as thiopental tend to relocalize from CNS to adipose tissues resulting in redistribution of drug and short duration of action Concentration of Drug in the Body The extent of protein drug binding can change with both changes in concentration of drugs and proteins. It becomes significant when the conc: of protein (AAG) involved in binding is less and such case the drug (lidocaine) even at therapeutic conc: can saturate the binding protein resulting in increase free plasma drug concentration and which may enhance clinical response or toxicity. Affinity of a drug for a particular binding component: Lidocaine has greater affinity for AAG than for HSA. Digoxin has more affinity for proteins of cardiac muscles than those of skeletal muscles or plasma. Which results in specific tissue storage or specific site of action and even toxicity. PROTEIN/TISSUE RELATED FACTORS Physicochemical Properties of Protein/Binding Component Lipoproteins and adipose tissue tend to bind lipophilic drugs by dissolving them in the lipid core. Physiologic pH determines the presence of active anionic and cationic groups on the albumin to bind a variety of drugs. Concentration of Protein/Binding Component Mostly all drug bind to albumin b/c it present a higher concentration than other protein number of binding sites on the protein. General pharmacology
62 Number of Binding Sites on the Protein Albumin has a large number of binding sites as compared to other proteins and several drugs are capable of binding at more than one site on albumin and can result in drug interaction. (See above) DRUG INTERACTIONS (See displacement Interactions and toxicity) Miscellaneous factors Age Neonate albumin content is low in new born as result in increase conc. of unbound drug that primarily bind to albumin eg. Phenytoin , diazepam Elderly -albumin content is lowerd result in increase conc. of unbound drug that primarily bind to albumin . In old age AAG level is increase thus decrease conc. of free drug that bind to AAG Disease state Disease Influence on plasma protein Renal failure (uremia) albumin content Influence on protein drug binding Decrease binding of acidic drug , neutral or basic drug are Hepatic failure Albumin synthesis unaffected Decrease binding of acidic General pharmacology
63 drug, binding of basic drug is normal or reduced depending on AAG Inflamma tory state (trauma , burn, infection ) AAG levels level. Increase binding of basic drug , neutral and acidic drug unaffected .
64 Intersubject Variations Intersubject variability in drug binding as studied with few drugs showed that the difference is small and no more than two fold. These differences have been attributed to genetic and environmental factors. 4. MISCELLANEOUS FACTORS AFFECTING DRUG DISTRIBUTION Diet: A Diet high in fats will increase the free fatty acid levels in circulation thereby affecting binding of acidic drugs such as NSAIDS to Albumin. Obesity: In Obese persons, high adipose tissue content can take up a large fraction of lipophilic drugs. Pregnancy: During pregnancy the growth of the uterus, placenta and fetus increases the volume available for distribution of drugs. Disease States: Age Differences in distribution pattern of a drug in different age groups are mainly due to differences inTotal body water (both intracellular and extracellular) - is much greater in infants Fat content - is also higher in infants and elderly Skeletal muscles - are lesser in infants and in elderly Organ composition - the BBB is poorly developed in infants, the myelin content is low and cerebral blood flow is high, hence greater penetration of drugs in the brain Plasma protein content - low albumin content in both infants and in elderly General pharmacology Altered albumin or drug binding protein conc. Altered or reduced perfusion to organs /tissues Altered Tissue pH
65 Drug Interactions Drug interactions that affect distribution are mainly due to differences in plasma protein or tissue binding of drugs. (See displacement Interactions and toxicity) REDISTRIBUTION The typical mode of distribution observed particularly with highly lipid soluble drugs when given by i.v. or by inhalation. Such drugs initially get distributed to organs with high blood flow, e.g. brain, heart, kidney etc. Later, less vascular but more bulky tissues (muscles, fat) take up the drug and plasma concentration falls and drug is withdrawn from this sites. If the site of action of the drug was in one of the highly perfused organs, redistribution results in termination of the drug action. Greater the lipid solubility of the drug, faster is its redistribution. Thiopental, a drug with highest lipid solubility enter the CNS rapidly and used as induction agents in anesthesia but the CNS effects are terminated by rapid redistribution of the drug from the brain to adipose tissue and skeletal muscle hence known as ultra short acting barbiturate. But if the same drug is administered repeatedly the less vascular site of redistribution becomes saturated resulting increase in duration of action.
66 Chapter VI DRUG METABOLISM OR BIOTRANSFORMATION On entering the body, drugs are treated as if they are toxic substances, which need to be detoxified and eliminated as soon as possible. Metabolism involves changes to the molecular structure of a substance and these changes are produced by the action of enzymes. Biotransformation is defined as the enzyme catalyzed chemical transformation of drugs with in the living organism by which the drug is either inactivated or made polar so that they are not reabsorbed but excreted easily This has two important effects on drug molecules: 1. The drug is made more water soluble (polar) and therefore more easily excreted by the kidneys. 2. The metabolites are usually less pharmacologically active than the parent drug (inactivation). This is not always the case. A drug metabolite may have a new and completely different pharmacological activity, or it may be as active as or more active than the original drug. Some drugs have to be metabolized in order to become active. Prodrugs are drugs that have been designed to remain inactive until they have been metabolized by the body. Fate of biotransformation can be any one of the following: 1. 2. 3. 4. Active to inactive metabolite (e.g. Phenobarbitone to Hydroxyphenobarbitone) Active to active metabolite (e.g. Diazepam to Oxazepam) Inactive to active metabolite (e.g. Levo DOPA to Dopamine) Active to toxic metabolite (e.g. Paracetamol to N-acetyl-P-benzoquinoneimine) Most tissues in the body have the enzymes capable of metabolizing a variety of substances major one being liver and others in their decreasing order of importance are: lungs>kidney>intestine>placenta>adrenal gland>skin
67
Organ of metaboli sm Liver Lungs
Drugs metabolized
Phenobarbitone, paracetamol Nicotine
Kidney Nicotine, Intestine Placenta Skin Isoprenaline Insulin, Digoxin L-DOPA Minoxidil Metabolic reactions There are two general types of metabolic reactions, Phase 1 and Phase 2 reactions. Some drugs undergo both Phase 1 and Phase 2 reactions, but, depending on its chemical nature, it is possible for a drug to be metabolized by either type of reaction only. Drug metabolizing enzymes They broadly divided in two classes: Microsomal and Non microsomal enzymes Microsomal enzymes These enzymes are located on microsomes, vesicle-like artifacts formed from the smooth endoplasmic reticulum primarily present in liver also in kidney, intestinal mucosa and lungs.
68 They catalyzes majority of drug metabolic reactions especially Phase I reactions and the Phase II Glucuronidation E.g monooxygenase, hydroxylase, reductase and glucuronyl trasferase Characteristics Microsomal enzymes The intact nature of the lipoidal membarane bound enzyme of the microsomes is essential for its selectivity towards the lipid soluble drugs enzymes. Lipid soluble substrate is biotrasformed in to a water soluble metabolite by the microsomal Water soluble substrate generally does not interact with these enzymes. These enzymes are inducible by drugs (phenobarbitone) and food. Among the microsomal enzymes glucuronyl transferase is unique It catalyses phase II reaction while all others phase I. It is the only microsomal enzyme which is active in soluble cell fractions. It can catalyze the conjugation reaction of a number of endogenous molecules like bilirubin. Non microsomal enzymes They are present in soluble form in the cytoplasm and also attached to mitochondria but not to endoplasmic reticulum. Non specific enzyme catalyzes few oxidative reactions and a number of reductive, hydrolytic and importantly all conjugation reactions except glucuronidation. e.g. peroxidases, dehydroganases, esterases, transferases Characteristics enzyme General pharmacology Active in soluble cell fractions They are non inducible one but shows high genetic variations e.g N- Acetyl Transferase Water soluble substrate including endogenous substances generally interact with these enzymes which can be readily excreted. A number of lipid soluble substrate can interact non-specifically with the microsomal
69 Phase I reaction/ functionalisation reaction/ non synthetic reaction: it is the reaction in which a polar functional group[ ( -OH,-COOH,-NH2) is either introduced or unmasked if already present on the otherwise lipid soluble substrate. Phase I reaction is mainly carried out by microsomal enzymes(cyt P450), usually involve oxidation, reduction, hydrolysis and rarely by non microsomal enzymes( MAOs, alcohol dehydrogenase). Phase II reaction / conjugation reaction/ synthetic reaction: it involves covalent attachment of small polar endogenous polar substances like glucuronic acid, glutathione , glycine, sulphate,methyl group etc to the phase I product and forms highly water soluble product which excreted easily, hence a real drug detoxification reaction. Phase II reaction is mainly carried out by non microsomal enzymes( oxidases, esterase etc.), usually involve glutathione, glycine, sulphate or methyl conjugation and by only one microsomal enzymes, glucuronide transferase for glucuronide conjugation.
70 Phase 1 reactions Phase 1 reactions involve the biotransformation of a drug by one or more of the following reactions to a more water-soluble metabolite, which is more likely to be excreted by the kidney or go on to Phase 2. This may some time increase the toxicity of some drugs. Phase I Reactions 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Oxidation Reduction Hydrolytic cleavage Alkylation (Methylation) Dealkylation Ring cyclization N-carboxylation Dimerization Transamidation Isomerization Decarboxylation Oxidation is the most important and commonest type of metabolic reaction, which involves the addition of oxygen to the drug molecule.oxidative reaction increases the hydrophilicity of xenobiotics and such metabolite rapidly undergo either undergo phase II reactions or excreated by the kidney. 1. In the liver, oxidation reactions are catalysed by a group of enzymes known as the
microsomal mixed function oxidase system (MFO) which require O2 and a reducing agent NADPH( also known as monooxygenase since it transfer only one oxygen atom and as hydroxylase since the product of the reaction contains an OH functional group). This multienzyme MFO consists of 3 components; 2. monoxide 3. Cyt P450 reductase/ Cyt C reductase a flavoprotein, functions as electron acceptor Cyt P450 a is a haeme protein containing an iron atom which can alternate between the ferrous (Fe++) and ferric (Fe+++) states named based on its light absorption at 450 nm when complexed with carbon
71 4. NADPH to Cyt P450
Phosphatidyl choline, a heat stable lipid component which facilitate electron transfer form
NADP+
Drug CYP eR-Ase CYP Fe+3

PC
Drug
Drug OH CYP Fe+3 Drug OH e-
NADPH
CO
CYP-Fe+2 Drug
CO
CYP Fe+2 Drug O2 O2 CYP Fe+2 Drug
H2O 2H+
Electron flow in microsomal drug oxidizing system
Some of the important phase I metabolic reactions are given below: Oxidation Oxidation is the addition of oxygen and/or the removal of hydrogen. Most oxidation steps occur in the endoplasmic reticulum. Common reactions include :Alkyl group ----> alcohol
for example phenobarbitone
72 Aromatic ring ----> phenol
for example phenytoin Oxidation at S or N
sulfoxide for example chlorpromazine In two steps oxidative dealkylation is possible
for example phenacetin Outside the microsomes - in liver and brain Monoamineoxidaze
for example 5-hydroxytryptamine
73 Alcohol dehydrogenase - in liver, kidney, lung
Reduction Add a hydrogen or remove oxygen azo (-N=N-) or nitro groups (-NO2) -----> amines (-NH2) for example nitrazepam Hydrolysis Addition of water with breakdown of molecule. In blood plasma (esterases) and liver Esters ---> alcohol and acid
for example aspirin to salicylic acid Amides to amine and acid
For example procainamide
74 Phase 2 reactions The most important conjugation reaction is with glucuronic acid to form a glucuronide. Other conjugations occur with sulfate, acetyl, methyl and glycine groups. Many drugs are metabolized by a combination of routes and this can vary from individual to individual and depends on the dose of drug, the presence of interacting drugs and the state of the liver. The moieties transferred may posses 3 characteristics: 1. 2. 3. Simple endogenous molecule Large molecular size Highly polar or ionic in nature The reactions are capacity limited due to the limited availability of endogenous conjugating molecules. Hence higher doses of the drugs can lead to the depletion of the endogenous conjugating molecules leading to toxicity. The molecular weight of the conjugate determines the route of excretion of drugs. E.g high molecular weight conjugate are excreted in bile while low molecular weight conjugate are excreted through urine. Glucuronidation (microsomal conjugation) is one of the most common mammalian Phase II conjugation pathways and the only phase II reaction catalyzed by microsomal enzyme. Parent drug or phase I product with COOH, -NH2 or mercapto group undergo this reaction. This reaction is carried out by a group of UDP- glucuronyl transferase enzyme. There are three steps to form the conjugate: 1. 2. 3. Coupling of D-glucose-1-phosphate to UTP to give UDP-glucose Oxidation of the primary alcohol yields the coenzyme UDP-glucuronic acid Conjugation with the substrate to yield the glucuronide by the enzyme UDP-glucuronyl
tranferase (microsomal enzyme) The polar hydroxyl groups of the glucuronide impart great water solubility, which facilitates excretion through urine. Some high molecular weight conjugates favors its excretion in bile and enzymatic cleavage by intestinal bacterial microbial flora releasing the parent drug and results in enterohepatic circulation. (Discussed later) General pharmacology
75 Glucuronidation example: drugs: nortriptyline, aspirin, paracetamol, diazepam etc Endogenous sub: thyroxin, bilirubin, steroidal hormones Acetyl Conjugation Acetylation results in a less hydrophilic metabolite (e.g.; an amine is converted into an amide). The physiological consequence is that it may deactivate a drug or its Phase I metabolites (if they are active as well) Acetylation involves two steps: 1. Cofactor acetyl-CoA activatesN- acetyltransferase 2.N-Acetytransferase transfers the acetyl group to the substrate. e.g. INH, Sulfonamides Amino Acid Conjugation Amino acid conjugation occurs for a variety of carboxylic acids and usually glycine or glutamineare conjugated with the drugs and the reaction is catalyzed by amino acid acyl Co-A transferase enzymes and excreated through urine. Glycine is the most common conjugating amino acid in mammals. The main metabolite is a glycine conjugate Paracetamol undergoes glucuronidation and Sulfation With increasing dose the glycine conjugation system becomes saturated With increasing dose both these systems become saturated glucuronide conjugation then becomes important then the drug is conjugated with glutathione With even higher doses the glucuronide system becomes saturated if this pathway becomes saturated a hepatotoxic metabolite accumulates and hepatotoxicity, results not from paracetamol itself, but from one of its metabolites, N-acetyl-p-benzoquinoneimine (NAPQI). NAPQI depletes the liver's natural antioxidant glutathione and directly damages cells in the liver, leading to liver failure. Acetylcysteine also called N-acetylcysteine or NAC, works to reduce paracetamol toxicity by replenishing body stores of the antioxidant glutathione. Glutathione react
76 with the toxic NAPQI metabolite so that it does not damage cells and can be safely excreted. e.g. aspirin, nicotinic acid
77 Sulfate Conjugation through urine. There are three steps that occur with sulfate conjugation: 1. Activation of inorganic sulfate by ATP 2. Phosphorylation of the 3 OH to generate the sulfation cofactor. 3. conjugation with the substrate to yield the sulfate conjugate. Glutathione Conjugation Glutathione (GSH) is a tripeptide and is found in nearly all mammalian tissues. Conjugation of this sort occurs in the cytoplasm of most cells, especially in the liver and kidney where the GSH concentration is 5-10 mM. Its apparent function is to scavenge potentially harmful electrophilic compounds (either xenobiotics or their metabolites).This chemical basis for its function is reactive nucleophilic thiol group. The conjugation is mediated by the enzyme glutathione S- transferase (GST) although with more reactive electrophiles the conjugation may occur nonenzymatically. Glutathione conjugation differs from the previous Phase II reactions since electrophiles (rather than nucleophiles) are subject to conjugation. Glutathione can to conjugate to many types of electrophilic species Once formed, GSH conjugates further acted up on by - glutamate transpeptidase and cysteinyl glycinase and finally excreted as N-acetylcysteine conjugates. This pathway is considered by some to be Phase III metabolism. e.g. ethacrynic acid, paracetamol Methylation The amine and phenols under go such reaction and it is catalyzed by transmethylase enzyme and methionine and cysteine acts as co-factor (methyl donors) e.g. adrenaline, histamine, methyl DOPA The most common substrates that undergo sulfate conjugation are phenols
and sterols by the enzyme sulfotransferase. The products are highly water soluble and excreted
78
79 Miscellaneous reaction Hofmann elimination It refers to the elimination of the drugs in the body fluids by spontaneous molecular rearrangement with out the agency of an enzyme. E.g. atracurium Factors affecting metabolism of drugs 1. 2. 1. 2. 3. 4. 5. 6. 7. 8. Physicochemical properties of the drug Chemical factors Enzyme induction Enzyme inhibition Biological factors Age Sex Species Race Genetic Variation Nutrition and Diet Disease 1. Physicochemical properties of the drug like molecular size, shape, pKa. Acid or basic in nature, lipophilicity, steric or electronic characteristics can affect the interaction of the drug with enzymes 2. Chemical factors Enzyme induction (Microsomal Enzyme induction) The phenomenon of increased drug metabolizing ability of the enzymes induced by several drugs or chemicals are called Enzyme induction since microsomal enzymes are only inducible it is also known as Microsomal Enzyme induction. This occurs when a drug is administered over a period of time. Its signicance is that other drugs metabolized by the same enzymes are metabolized faster and therefore
80 circulate in a lower concentration than expected for a given dose. This could mean that they become ineffective. Alternatively, a drug could be metabolized faster than expected into a
81 toxic compound. The mechanisms involved in enzyme induction are unclear but somehow DNA sequences are affected so that production of the relevant enzyme is increased.Examples of drugs that are well known to cause enzyme induction are carbamazepine,phenytoin (both antiepileptics) and alcohol. The agents which induces the enzyme are known as inducers Enzyme induction, although most prominent in liver like cytochrome P-450 and glucuronyl transferase enzymes, also occur to some extent in the lung, and kidney e.g. cytochrome P-450-1AI isoenzyme is induced in the lungs of cigarette smokers. Since enzyme induction requires the synthesis proteins, it occurs gradually over a period of 1-2 weeks to attain its maximal effect and require an equal time to dissipate the effect after the enzyme induction. Significance 1. The induction results in an accelerated metabolism and a decreased pharmacological
response of not only the inducer itself (self inducers, e.g rifampin) but also co-administered drugs utilizing the same metabolic pathway. e.g failure of oral contraceptives when administered with phenytoin 2. 3. 4. 5. 6. If the drug biotransformation produces an active or a toxic metabolite, enzyme induction may Tolerance development: acceleration of metabolism and a decreased pharmacological Rapid metabolism of endogenous substances. E.g. steroids by barbiturates Intermittent use of inducers may interfere with dose of another drug prescribed in regular Interfere with chronic toxicity studies in animals Beneficial uses of Enzyme induction 1. phenobarbitone. 2. of adrenal steroids. 3. 4. Chronic poisioning by accelerating the metabolism of accumulated poisons. In liver diseases to improve the enzyme function. General pharmacology Symptomatic treatment of Cushings syndrome with phenytoin which increases degradation Treatment of congenital non hemolytic jaundice / kernicterus with enzyme inducer exacerbate the activity or toxicity respectively e.g. paracetamol toxicity by alcohol response of the inducer itself (self inducers, e.g rifampin)
basis. E.g. oral anticoagulants affected by phenytoin
82 Enzyme inhibition The phenomenon of decreased drug metabolizing ability of the enzymes by several drugs or chemicals are called Enzyme inhibition It can be direct by competitive or non competitive and indirect by repression (decrease enzyme content) or altered physiology (hormonal imbalance or nutritional deficiency). One drug may inhibit the metabolism of another drug with resultant increase in the circulating levels of the slowly metabolized drug and prolongation or potentitation of its pharmacological effects. The enzyme inhibition can either be of hepatic microsomal mixed function oxidase (MFOs) or of enzymes having specific functions, e.g. xanthine oxidase, monoamino oxidase and aldehyde dehydrogenase etc. Enzyme inhibition, unlike induction, is a rapid process but is usually reversible. However, it could also be irreversible as in the case of secobarbital. These drugs, in the course of their metabolism by cytochrome P-450, inactivate the enzyme and end up in an impairment of their own metabolism and that of other drugs (unlike Phenobarbital which is an enzyme inducer). Significance 1. Increase adverse effects of the drug affected. E.g. Unexpected nausea/vomiting due to
theophylline with concomitantly administered chloramphenicol/ Enhanced bleeding tendency with dicumarol when administered with cimetidine, Erythromycin, an antibiotic, similarly increases the activity of theophylline, warfarin and digoxin (used in cardiac failure) due to the destruction of normal microbial flora. Beneficial uses of enzyme inhibition 2. Increase availability of the drug at the site of action and hence reduction in the dose required.
E.g Increased accessibility of 1-dopa in brain when given along with carbidopa (peripheral Laminoacid decarboxylase inhibitor) 3. Reduction in the side effect if the metabolite is responsible for the side effects. e.g 1-dopa when given along with carbidopa reduced conversion of l dopa to dopamine in the periphery reduces the cardiac and other peripheral side effects of l dopa
83 4. 5.
Aversion to alcohols by retarding the metabolism of the toxic intermediate metabolite of Reversal of skeletal muscle paralysis caused by skeletal muscle relaxants like d-TC using
alcohol acetaldehyde by inhibiting the enzyme acetaldehyde dehydrogenase by the drug disulfiram. enzyme inhibitor neostigmine (acetyl cholinesterase reversible inhibitor). Biological factors Age Neonates have low microsomal enzyme and glucuronyl transferase enzyme activity and these attain full functional capacity several weeks after the birth. Thus neonates are potentially predisposed to the life threatening cyanotic condition, called 'grey baby syndrome' after administration of chloramphenicol due to reduced conjugation and excretion of the drug. Similarly,-the diminished activity of glucuronyl transferase in-neonates contributes to the risk of kernicterus when free bilirubin levels in plasma are increased due to displacement of bilirubin from albumin binding sites after giving sulfonamides. Elderly persons, above the age of 60, have a reduced hepatic blood flow. Hence metabolism of drugs, like propranolol, lidocaine and pethidine (whose rate of metabolism is governed by hepatic blood flow) exhibit slow metabolism and increased incidence of toxicity. Sex The differences in the rate of metabolism due to sex are important in various animal species but are seldom important in human beings. Male rats sleep for a shorter duration than females, after receiving hexobarbital, as their microsomal enzyme activity is higher than in females. Species Rabbits metabolize atropine faster than man as they have high atropine esterase activity in the liver and plasma. Similarly, rate of barbiturate metabolism is higher in mice as compared to rats, dogs and men in a decreasing order.
84 Race .Chinese have a high alcohol dehydrogenase but a low aldehyde dehydrogenase activity. Hence they exhibit higher plasma concentration of aldehyde (and therefore headache, palpitation etc.) after consuming alcohol. Similarly, although Chinese are more sensitive to cardiovascular effects of propranolol, they metabolize it considerably faster than whites. Genetic Variation Some well studied examples of genetic variation in the rate of drug metabolism are. The presence of Atypical pseudocholinesterase (inherited as autosomal recessive trait) retarde metabolism of Succinyl choline a depolarizing Neuromuscular blocker resulting in prolonged apnea due to paralysis of respiratory muscles Slow N-acetylation and Rapid N-acetylation (Inherited as an autosomal recessive trait) affects the metabolism of the anti tubercular drug Isoniazid. in the case of slow acetylation it causes accumulation of the drug and produce its characteristic side effect peripheral neuritis while its fast metabolism causes the increase production of its metabolite causing hapatotoxicity Nutrition and Diet The diet rich in protein and low in carbohydrate enhances the rate of metabolism of many drugs. Rich protein diet supplies glycine and cysteme which are essential to form conjugated metabolites of the drug. On the other hand, diets very poor in protein and rich in carbohydrate slow down the rate of drug metabolism (e.g. starvation leads to enzyme inhibition). Deficiency of vitamin A, vitamin C, calcium, and magnesium also impair the drug metabolism and increase the individual's sensitivity to different drugs. Disease The activity of hepatic cytochrome P-450 linked enzymes are impaired to varying degrees in a
85 number of pathological states, like viral hepatitis, alcoholic hepatitis, active or inactive liver cirrhosis, hepatocellular carcinoma and heavy metal poisoning. Analogously, cardiac diseases by
86 limiting the blood flow to liver may impair disposition of drugs like propranolol whose metabolism is flow limited. Hypothyroidism decreases the metabolism of digoxin, methimazole while hyperthyroidism enhances the rate of metabolism of various drugs.
87 Chapter VII EXCRETION OF DRUGS Drugs are potentially toxic substances and must be eliminated by the body as quickly as possible. Drugs are eliminated from the body either unchanged or as water soluble metabolites. Both e processes of metabolism and excretion are essential for the elimination of drugs from the body. The major routes of drug excretion are: Renal, Biliary, Fecal, Alveolar, the minor routes of drug excretion include: Milk, Skin, Hair, Sweat, aliva. Renal Excretion Kidney is the most important organ for -elimination of free drugs (e.g. frusemide, gentamicin, tubocurarine and digoxin) and their metabolites. The three key processes that deterne the renal excretion of drugs are 1. 2. 3. Glomerular filtration Active tubular secretion and Passive tubular reabsorption i) Glomerular FiltrationGlomerular filtration is the transfer of fluid and solutes from the glomerular capillaries along a pressure gradient into Bowman's capsule. Several factors influence the-renal excretion by glomerular filtration: Molecular size: as drugs having small molecular size are more readily filtered. Usually the drugs having molecular weight above 20,000 are unable to be filtered. Thus macromolecular substances like heparin, dextran, insulin and growth factors (irrespective of their protein binding) are unable to pass through glomerulus, Plasma protein binding.- as only the free drugs can be filtered through glomerulus, while protein binding decreases the renal excretion. It is the extent of protein binding that is the filtration rate limiting factor. For example, a drug like wafarin which is 98% bound to albumin, is excreted to an extent of only 2% through glomerulus, General pharmacology
88 Renal blood flow: as greater the glomerular perfusion, faster is the drug removal from the plasma. Tubular Secretion Glomerular filtration removes at the most 20% of the drug from the blood reaching the kidney. The rest 80% of the drug passes on to the proximal tubule from where it is secreted into the tubular lumen. Tubular secretion is an energy requiring carrier mediated active transport, hence protein binding, which is a hindrance for glomerular filtration does not interfere with the tubular secretion There are two independent carrier systems operating at this level.For acidic drugs, like penicillins, salicylic acid, thiazide diuretics, nitrofurantoin, nalidixic acid, probenecid, indomethacin, methotrexate, sulfonamides, radiocontrast media, glucuronide metabolites of these drugs and for some endogenous substances, like uric acid. For basic drugs, like morphine, quinidine, procaine, quinine, neostigmine, quaternary ammonium compounds and for some endogenous substances, like dopamine, choline, histamine and serotonin. Each carrier system is relatively non selective and therefore the drugs having similar physico-chemical characteristics compete for the same carrier system. For example, probenecid (a weak acid) competitively inhibits the tubular secretion of penicillins and amoxicillin thereby increasing the plasma half life and of festiveness of penicillins in the treatment of certain infective diseases. Similarly, weakly acidic drugs (e.g. lactic acid, salicylic acid and thiazide( diuretics) interfere with the secretion of an endogenous substance, uric acid, with resultant rise in plasma uric acid levels sufficient to precipitate the attack of gout in predisposed individuals. However, there are no drugs which can be used clinically to block the active secretion o basic drugs. iii) Tubular Reabsorption The renal tubule behaves like a typical lipid barrier especially in the distal region. Hence the reabsorption of drugs through the distal tubules predominantly takes place by passive diffusion and its extent is dependent upon the (i) lipid solubility, (ii) ionization constant (pka) of the drug and (iii) pH of the urine.
89 Since the pH of the urine is acidic, all acidic drug (e.g. salicylates, barbiturates and sulfonamide remain predominantly nonionised and hence more chances of their reabsorption than excretion.. If the pH of the urine made alkaline by giving sodium bicarbonate sodium citrate, the ionization of acidic drug would increase. As a result their reabsorption would be retarded while excretion would be facilitated. Hence alkalinisation of urine is used in the cases of salicylate or barbiturate poisoning. Weakly basic drugs, like morphine or amphetamine are predominantly excreted in acidic urine (due to their high ionisation). Their excretion can further be hastened by making urine more acidic by giving ascorbic acid. If the pH of the urine is made alkaline, their reabsorption would increase while excretion would be retarded. Strongly acidic or basic drugs remain ionised at all pH ranges and hence are not reabsorbed (rather excreted). Quaternary ammonium compounds and aminoglycoside antibiotics being highly polar drugs are not reabsorbed (rather primarily excreted). Biliary Excretion and Enterohepatic Circulation Liver cells transfer various drugs and endogenous substance like bilirubin, from plasma to bile by means of a transport system similar to that of the renal tubule. Independent carrier systems are utilized by acidic and basic drugs. Hepatocytes serve as a third transport system for neutral substances like steroids. Drugs that show significant elimination through bile include: quinine, colchicine, vinblastin, dtubocurarine, vecuronium, corticoste-roids, erythromycin and chlorpromazine. These are then subsequently eliminated through faeces. The reabsorption of the parent drugs (digitoxin, Indomethacin) that are secreted through bile in to the intestine, or certain drug metabolites (thyroxine, morphine, chloramphenicol, tetracycline, phenolphthalein, ethinyl estradiol )(particularly the glucuronides) are excreted through bile in to the intestine which are deconjugated or hydrolysed releasing the parent active drug again from the intestine back to the systemic circulation and this cycle continue which is reffered to as enterohapatic recycling. General pharmacology
90 Significance of Enterohepatic Circulation 1. 2. oral contraceptives 3. 4. Important for the conservation of important endogenous substances like Vit B12, Vit D3, Drug interactions. The destruction of normal microbial flora by drugs like broad spectrum folic acid, steroidal hormones, bile salts etc. antibiotics retard the hydrolysis of the drug conjugates and their Enterohepatic reabsorption resulting in decreased effectiveness of the drug. 5. Toxicological importance: The toxicity of DDT is due its enterohepatic cycling and its accumulation in the body. Such cases the unabsorbable ion exchange resins like cholestyramine etc which binds to these chemicals and prevent their enterohepatic cycling can be used to treat the poisoning. Fecal Elimination Substances excreted in faeces are mainly Orally ingested drugs which are not absorbed through the gut, e.g. magnesium sulfate, streptomycin, neomycin, bacitracin, cholestyramine and certain purgatives, Certain drugs (or their metabolites) which are excreted through bile but are not reabsorbed from the intestinal tract e.g. erythromycin, chlorpromazine and corticosteroids. Alveolar Excretion Gases and volatile liquids, e.g. general anaesthetics, nitrous oxide, ether, paraldehyde and alcohol are eliminated through breath, irrespective of their lipid solubility, because the excretion of drugs here depends on their partial pressure in the blood. Certain essential oils like eucalyptus oil and garlic oil are eliminated through expectoration. Excretion through Breast Milk The net result of enterohepatic circulation is the prolongation of drug action as it serves as a Increase in the plasma t half and duration of action of the drugs. E.g. the long 12 hr action of
small circulating reservoir.
91 Excretion of drugs in the breast milk is important, not because of the amount excreted but because of the unwanted pharmacological effects in the nursing infant. Drugs are transferred to the breast milk according to pH partition principle. Therefore, the basic drugs, being predominantly nonionised at plasma alkaline pH can diffuse through the mammary epithelium and get accumulated in the milk. Once diffused to milk these drugs cannot be reabsorbed back to plasma, because in the acidic pH of milk they get substantially ionised. Hence, as a rule, basic drugs, e.g. chloramphenicol, tetracycline, ergotamine, morphine, metronidazole, carbimazole, certain immunosuppressive/cytotoxic drugs, bromocriptine, estrogen/ progesterone oral contraceptives, diazepam, antihistamines and senna alkaloids (purgatives) are excreted more through milk as compared to acidic drugs. Certain non-electrolytes like ethanol and urea readily enter the breast milk, independent of the milk pH. Certain acidic drugs, although being less secreted, can cause serious side effects in infants, e.g. sulfonamides (kernicterus and allergy), penicillins (allergy), ampicillin (diarrhoea), dapsone (haemolytic anemia), phenindione (bleeding), phenobarbitone (drowsiness), phenytoin (methaemoglobinemia) and theophyllin (restlessness). Infants are particularly sensitive to drug induced hemolysis during neonatal period (some infants may also have G6PD deficiency). Hence, the following drugs should also be avoided (or be administered with caution) in breast feeding mother, e.g. chloramphenicol, chloroquine, primaquine, quinine, quinidine, procainamide, nitrofurantion, nalidixic acid, dapsone, isoniazid, probenecid and cotrimoxazole (sulfonamides in general). Excretion Through Skin, Hair, Sweat and Saliva Elimination of drugs through these routes is quantitatively unimportant. To cite a few examples, griseofulvin is secreted through keratin precursor cells; arsenic, mercury salts and iodides are secreted through hair follicles; iodine, potassium iodide, lithium and phenytoin are secreted through saliva while certain amines and urea derivatives are secreted through sweat.
92
Kinetics of Elimination First order kinetics The rate of elimination is directly proportional to the drug concentration, CL remains constant. A constant fraction of the drug present in the body is eliminated in unit time. Most of the drugs are eliminated by First order kinetics
Zero order kinetics The rate of elimination remains constant irrespective of drug concentration, Cl decreases with increase in concentration. Here constant amount of drug is eliminated in unit time. Example: Ethyl alcohol
93 C a te V h p r III P A MC D N M S H R A O Y A IC (What Drugs do to a Living Organism?) Pharmacodynamics includes the study of physiological and biochemical effects of drugs and their mechanism of action at macromolecular / sub cellular / organ system level. Hence it involves all the actions of the drug either useful or adverse or even fatal. Pharmacodynamic actions of the drugs can be summarized as follows: PHARMACODYNAMIC
Desirable beneficial effect (Therapeutic effect)
Undesirable effect (Adverse effect)
Expected undesirable effect effect
Unexpected undesirable
Side effects
Secondary Side effect
Toxicity
Hypersensitivity
Genetically determined
Idiosyncrasy
94 It is important to distinguish between actions of drugs and their effects. Actions of drugs are the biochemical physiological mechanisms by which the chemical produces a response in living organisms. The effect is the observable consequence of a drug action. For example, the action of penicillin is to interfere with cell wall synthesis in bacteria and the effect is the death of the bacteria. One major problem of pharmacology is that no drug produces a single effect. The primary effect is the desired therapeutic effect. Secondary effects are all other effects beside the desired effect which may be either beneficial or harmful. Drugs are chosen to exploit differences between normal metabolic processes and any abnormalities which may be present. Since the differences may not be very great, drugs may be nonspecific in action and alter normal functions as well as the undesirable ones. This leads to undesirable side effects. The biological effects observed after a drug has been administered are the result of an interaction between that chemical and some part of the organism. BASIC PRINCIPLES OF DRUG ACTION Drugs except gene based do not impart ant new function to ant system, organ or cells but only alter the phase of ongoing activity. Based on this the principles of drug action are the following: Stimulation: It is the selective enhancement of the level of activity of a specialized cells.e.g. drug pilocarpine stimulate salivary glands Depression: It is the diminution or depression of the activity of specialized cells e.g. barbiturates depress the CNS, atropine inhibit the secretary activity of salivary glands Irritation: It is a non selective often noxious effect and particularly applied to less specialized cells e.g bitter tonic increase the salivation and gastric acid secretion by its irritant action. Replacement: It is the replacement of ant endogenous substance to overcome its deficiency e.g. iron supplement in anemia, insulin in DM Cytotoxic action: It is the use the selective toxic action of certain drugs to kill micro organisms or malignant cells e.g. antibiotics, anti cancer drugs.
95 General mechanisms of drug actions Physical actions: the action of the drug is due to its physical properties like adsorption, osmosis, etc.e.g. Adsorption of chemicals by charcoal used in poisoning, osmotic diuretic like mannitol, bulk laxatives like isapgol. Chemical properties are also exploited for drug action like the acid base reaction to reduce acidity using antacids like aluminum hydroxide gel, EDTA as chelating agent in heavy metal poisoning. Enzymes as targets of drug action: since the biological reactions are carried out under the catalytic influence of enzymes they are considered as important targets of drug action. Drugs can act either by stimulating or by inhibiting the enzymes The stimulation of enzyme activity is unusual though relevant for natural metabolites like pyridoxine which is a co-factor for the enzyme decarboxylase. Several enzymes are stimulated indirectly through receptors e.g. adrenaline stimulates receptors in liver which in turn stimulate the enzyme hepatic glycogen phosphorylase via second messengers. Another way of stimulation of enzyme activity is through enzyme induction. It is the phenomenon of increased drug metabolizing ability of the enzymes induced by several drugs or chemicals are called Enzyme induction since microsomal enzymes are only inducible it is also known as Microsomal Enzyme induction.(refer factors affecting metabolism) Inhibitions of enzymes are more common. An enzyme inhibitor is a molecule that binds to enzymes and decreases their activity. The binding of an inhibitor can stop a substrate from entering the enzyme's active site and/or hinder the enzyme from catalyzing its reaction. It can be non specific, ie many chemicals can inhibit the enzymes coming in contact with them nonspecifically by denaturing their protein structure.e.g heavy metals, phenols etc. While specific enzyme inhibitions of are common in case of drugs. Such enzyme inhibition can be either reversible or irreversible. Irreversible inhibitors usually react with the enzyme and change it chemically. These inhibitors modify key amino acid residues needed for enzymatic activity. General pharmacology
96 There are four kinds of reversible enzyme inhibitors. They are classified according to the effect of varying the concentration of the enzyme's substrate on the inhibitor. In competitive inhibition. This usually results from the inhibitor having an affinity for the active site of an enzyme where the substrate also binds; the substrate and inhibitor compete for access to the enzyme's active site. This type of inhibition can be overcome by sufficiently high concentrations of substrate. Competitive inhibitors are often structurally similar in structure to the real substrate.e.g. neostigmine is competitive inhibitor of acetyl choline esterase enzyme. Non-competitive inhibition where the inhibitor and the substrate may both be bound to the enzyme at any given time. When both the substrate and the inhibitor are bound, the enzyme-substrate-inhibitor complex cannot form product and can only be converted back to the enzyme-substrate complex or the enzyme-inhibitor complex. The inhibitor binds only to the substrate-enzyme complex and inhibits the activity of that complex.e.g Noncompetitive inhibitors of CYP2C9 enzyme include nifedipine, tranylcypromine, phenethyl isothiocyanate, and 6-hydroxyflavone. In allosteric inhibition: this type of inhibition generally results from an allosteric effect where the inhibitor binds to a different site on an enzyme. Inhibitor binding to this allosteric site changes the conformation (i.e., tertiary structure or three-dimensional shape) of the enzyme so that the affinity of the substrate for the active site is reduced.As a result, the extent of inhibition depends only on the concentration of the inhibitor. This type of inhibition cannot be overcome by sufficiently high concentrations of substrate. e.g omeprazole inhibition of H+/K+ ATPase enzyme. Irreversible inhibitors usually covalently modify an enzyme, and inhibition cannot therefore be reversed. Irreversible inhibitors often contain reactive functional groups such as nitrogen mustards, aldehydes, haloalkanes, alkenes, Michael acceptors, phenyl sulfonates, or fluorophosphonates. These electrophilic groups react with amino acid side chains to form covalent adducts.e.g. organophosphorus is an Irreversible inhibitor of acetyl choline esterase enzyme. Ion channels as drug target. Drugs can act via proteins which act as ion selective channels, participating in transmembrane signaling and regulate intracellular ionic composition. The interaction of drug with ion channels can be either indirectly through receptors (discussed later) or directly by binding to it e.g. local anesthetics act by directly inhibiting voltage gated ion channels. General pharmacology
97 Transporter proteins as drug target. Drugs can directly interact with solute carrier class of transporter proteins to inhibit the on going physiological transport of the metabolites/ ions.e.g. Amphetamine inhibit the neuronal reuptake of noradrenaline by amine trasporters in the adrenergic neurons Receptor as drug targets: Receptors are considered as the main target of drug actions. A large number of drugs acts through specific receptors which controls the functions of those cells/organs via controlling the activities of enzymes, ion channels, trasporter proteins/ structural proteins. Receptors are defined as macromolecules or the binding sites located on the surface or inside the effector cell that serves to recognize the signal molecule or the drug and initiate the response to it but itself has no other function. Drug / any molecule that binds selectively to a particular receptor are called as a LIGAND. A ligand has two important properties (i) AFFINITY, is the capability of a molecule to bind to a receptor and form a ligand receptor complex. Affinity is a common property for all ligands. (ii) INTRISIC ACTIVITY is the ability of the ligand to trigger the response after making ligand- receptor complex. Intrinsic activity is not a common property hence not shown by all ligands. A ligand can activate/ do nothing /activate in opposite direction/ partially activate a receptor. Hence based on this the ligands are classified as follows: AGONIST: is an agent that binds to a receptor (affinity) of a cell and triggers a response by that cell (intrinsic activity) that often mimic the action of a natural physiological signal molecule. Hence agonist has both affinity and intrinsic activity. E.g. nor adrenaline/ adrenaline is an agonist on adrenergic receptors. INVERSE AGONIST: is an agent that binds to a receptor (affinity) of a cell and triggers a response by that cell (intrinsic activity) in the opposite direction that of a natural physiological signal molecule/ an agonist. Hence agonist has both affinity and intrinsic activity but opposite to that of an agonist. E.g. - carbolines on benzodiazepine receptor. PARTIAL AGONIST: is an agent that binds to a receptor (affinity) of a cell and triggers a response by that cell (intrinsic activity) to a sub maximal level ( less than the threshold level) that of a natural physiological signal molecule/ an agonist. Hence agonist has affinity but sub maximal intrinsic activity. E.g. Pentazocine on opoid receptors. General pharmacology
98 ANTAGONIST: is an agent that binds to a receptor (affinity) of a cell and prevents the response /binding of the natural physiological signal molecule/ an agonist. Hence antagonist has only affinity no intrinsic activity. It can be competitive or non competitive. E.g. Atropine on cholinergic receptor. THEORIES OF DRUG ACTION THROUGH RECEPTORS 1) Clarks theory : In 1937 Clark propounded a theory of drug action based on occupation of receptors by specific drugs and that the pace of a cellular function can be altered by interaction of these receptors with the drugs. The interaction between two molecular species viz drug (D) and the receptor (R) is governed by law of mass action and the effect (E) is a direct function of the D-R complex formed. D+R DR E (Clarks equation)
Later it was realized that the occupation of the receptor is essential but not itself enough to bring a response. Hence the agonist must be able to activate the receptor i.e. to induce a conformational change in the receptor. The capability of a molecule to bind to a receptor and form a drug receptor complex is designated as affinity and the ability of the drug to trigger the response after making drug- receptor complex is designated as intrinsic activity and both are considered as independent properties. But all drugs need not have the said intrinsic activity for example partial agonist. Hence the all or none action is not a must at a receptor based on this a theoretical quantity(S) denoting the strength of the stimulus imparted to the cell by the D-R complex was interposed in the Clarks equation. Thus the equation became D+R DR S E
Hence the DR complex can generate a strong, weak or a negative S. Based on this the ligands can be: AGONIST: Has both affinity and maximum intrinsic activity (I A=1). E.g. nor adrenaline/ adrenaline is an agonist on adrenergic receptors. INVERSE AGONIST: Has both affinity and intrinsic activity but but with negative sign (I A between -1 and 0). E.g. - carbolines on benzodiazepine receptor.
99 PARTIAL AGONIST: Has affinity but sub maximal intrinsic activity(I A between 0 and 1).. E.g. Pentazocine on opoid receptors. ANTAGONIST: Has only affinity no intrinsic activity(I A=0). It can be competitive or non competitive. E.g. Atropine on cholinergic receptor. Note: Less that 1% of receptors available occupied by agonist can produce maximal effect indicating the presence of large receptor reserve or a number of spare receptors. 1) Two state receptor model: according to this the receptors are believed to exists in two interchangeable state viz Ra Ra Ri
(active form) and Ri (inactive form) and these two states exists in equilibrium during resting state.
In case of majority of receptors Ri state is favored at equilibrium and no signals are generated in the absence of agonist. An agonist (A) binds preferentially to the Ra conformation and thus shifts the equilibrium hence the Ra state predominate producing a response. Response A competitive antagonist (B) binds to the Ra and Ri with equally affinity hence the equilibrium is not altered so no response is produced and the much of the Ra are occupied by the antagonist hence when the agonist is applied only less Ra are available for agonist to bind and a less response in produced. RaB + Ra No response Partial agonist (C) has only slightly greater affinity for Ra than Ri hence equilibrium is only modestly shifted towards Ra even at high concentration producing sub maximal response. RaC + Ra Sub maximal response RiC +R RiB +Ri RaA + Ra Ri
100 Inverse agonist (D) has only affinity for Ri hence equilibrium is shifted towards Ri producing and opposite response that of agonist provided the resting state equilibrium was in favour of Ra state as in case on receptors exhibiting constitutional activation.e.g benzodiazepine receptors which produce appreciable intense signals even in the absence of an agonist. Ra Ri +RiD Opposite Response RECEPTORS There are mainly 4 types of receptor (signaling pathways) Type I -Ligand gated ion channels (ionotropic receptors) Type II -G protein coupled receptors (metabotropic receptors) Type III -Enzyme linked (thyrosine kinase ) receptors Type IV -Nuclear receptors Type I -Ligand gated ion channels (LGIC): Also known as ionotropic receptors, this group of channels open in response to specific ligand molecules binding to the extracellular domain of the receptor protein. Ligand binding causes a conformational change in the structure of the channel protein that ultimately leads to the opening of the channel gate and subsequent ion flux across the plasma membrane. Examples of such channels include the cation-permeable "nicotinic" Acetylcholine receptor, ionotropic glutamate-gated receptors and ATP-gated P2X receptors, and the anion-permeable -aminobutyric acid-gated GABAA receptor.Ion channels activated by second messengers may also be categorized in this group, although ligands and second messengers are otherwise distinguished from each other. These receptors are located on the cell membrane and are coupled directly to an ion channel. These channels opens when a ligand (agonist) binds to it and allows the flow of ion ( Ca2+, Na+, K+, Cl-) through these channels and elicit a cellular response in the form of depolarization or hyperpolarisation of the cell membrane.e.g nicotinic receptors for acetyl choline. General pharmacology
101 Certain LGIC have 20 ligand which binds to an adjacent site (allosteric site) to the 10 site and modulate the gating of the channels by the 10 ligand.e.g GABAA Cl- ion channels (10 ligand GABA & 20 ligands BZD and barbiturates) Some LGIC acts indirectly based on the presence or absence of certain substances in the cell which are not agonists. E.g ATP sensitive K+ channels in pancreatic cells ( activated by decrease in intracellular [ATP] while inactivate when it increase) Type II -G protein coupled receptors (GPCRs): also known as seven-transmembrane domain receptors, 7TM receptors, heptahelical receptors, serpentine receptor, and G protein-linked receptors (GPLR) or metabotropic receptors. GPCRs are integral membrane proteins that possess seven membrane-spanning domains or transmembrane helices. The extracellular parts of the receptor can be glycosylated. These extracellular loops also contain two highly-conserved cysteine residues that form disulfide bonds to stabilize the receptor structure These membrane bound receptors are coupled to the effector pathway through GTP binging protein called G-protein bound to the inner(cytoplasmic) face of the receptor. These G-proteins are a trimer of , , and subunits (known as G, G, and G, respectively) that is rendered inactive when reversibly bound to Guanosine diphosphate (GDP) (or alternatively, no guanine nucleotide) but active when bound to Guanosine triphosphate (GTP). During resting state the GDP is bound to the subunit and the activation of the receptor by agonist leads to the displacement of GDP with GTP and activate the subunit (The cell maintains a 10:1 ratio of cytosolic GTP:GDP so exchange for GTP is ensured). The activated the subunit carrying GTP dissociate from the other two subunits to yield a G-GTP monomer and a tightly interacting G dimer, which are now free to modulate the activity of other intracellular proteins. The free G-GTP monomer then activates the effector/ target cells (T) (these may be enzymes or ion channels). This is called as the "active state" or "switch on state". The GTPase of the a-subunit quickly hydrolyses GTP to GDP and the resultant -GDP unit then dissociates from the effector (T) and reunites with G dimer, completing the cycle and resulting the switch back to the "off state". The G dimer also shown to modulate certain effectors like receptor operated K + channels, adenylyl cyclase and phospholipace C activity. G proteins are distinguished by their subunit ibased on their action on the effector and they are
102
Type of G protein Gs
Second messengers or signaling path way
stimulates adenylyl cyclase and increase cAMP( adrenergic receptor)
Gi
This inhibits adenylyl cyclase and decrease cAMP(2 adrenergic receptor)
Go Gq G12, 13
Not yet clear Activates phospholipase C (PLC) and increase IP3 and DAG(cholinergic muscarinic(M3) receptors Regulate actin cytoskeletal remodeling in cells. G13 is also essential for receptor tyrosine kinase-induced migration of fibroblast and endothelial cells. Increase cGMP
Gt Golf
phosphodiesterase and there by decrease cGMP level ( in rods and cones phototrasduction) stimulates adenylyl cyclase and increase cAMP( in olfactory epithelium)
103
Primarily there are three G-protein coupled effector systems: (Intracellular Signal Transduction and the Second Messengers) (a) The adenylate cyclase: Cyclic AMP system (b) The phospholipase C: Insoitol phosphate system (c) Ion channels.
104 The adenylate cyclase: Cyclic AMP system The activation of GPCR linked with Gs protein causes the activation of adenylyl cyclase enzyme which raises the intracellular cAMP level in the target tissue. This cAMP act as second messenger and ellict various cellular effects primarily by activating various protein kinases which phophorylate and alter the functions of various enzyme, ion channels transporters, structural proteins etc.finally the cAMP is hydrolysed within the cells by phosphodiesterase enzyme to 5'AMP and thus the action is terminated. Examples activation of adrenergic receptor in cardiac smooth muscles activates cAMP dependent protein kinase which increases the activity of Ca" channels in the heart muscle. Phosphorylation of these channels increases the Ca+- entry into the cell, during action potential, thereby increasing the force of contraction of the heart muscle. In smooth muscle,( adrenergic receptor) cAMP dependent protein kinase phosphorylates another enzyme, myosin light chain kinase, which is required for contraction. Here phosphorylation inactivates the enzyme and thus accounts for smooth muscle relaxation. As discussed above, the stimulation of adenylyl cyclase is mediated by Gs protein while the receptors linked with Gi, inhibit adenylyl cyclase and thus reduce cAMP production. Examples include M2 receptors (muscarinic-cholinergic-M2) of cardiac muscle, adrenoceptors in smooth muscles and opioid receptors. Cyclic guanosine-3,5- monophosphate (cGMP) cGMP has established signaling roles in only a few cell types. Ligands detected by cell surface receptors stimulate membrane bound guanylic cyclase to produce cGMP, and cGMP acts by stimulating cGMP-depended protein kinase. The Phospholipase-C- Inositol Phosphate System. Some of the hormones (e.g. vasopressin and thyrotropin releasing hormone), neurotransmitters (on muscarinic - cholinergic receptor, catecholamine (x, receptor and serotonin 5HT2 receptor) and growth factors (platelet derived growth factors) bind to receptors linked to G-proteins (Gq) and activate the membrane enzyme phospholipase-C (PLC).
105 The stimulation of PLC leads to the hydrolysis of phosphotidyl inositol 4, 5-diphosphate (PIP2,) which is the phospholipid component of plasma membrane. On hydrolysis, PIP2 splits into two second messengers: diacylglycerol (DAG) and inositol1, 4, 5-tri-phosphate (IP 3). DAG remains confined to the membrane, while IP 3 ' being water soluble, diffuses through cytoplasm where it triggers the release of Ca'(third messenger)' from storage vesicles. The raised cytoplasmic concentration of Ca" promotes the binding of Ca" to calmoduline (Cam)-Ca" regulates the activities of various enzymes (responses like contraction, secretion and enzyme activation etc). DAG activates a phospholipid and the calcium sensitive protein kinase-C (PKC) which then phosphorylates specific protein (enzymes) substrates (S) leading to the response (e.g. release of hormones, increase or decrease in neurotransmitter release and inflammatory responses etc.) As in the cAMP system, multiple mechanisms exist to damp or terminate signaling by phosphoinositide pathway. IP 3 is inactivated by dephosphorylation to inositol and then to phosphotidyl inositol monophosphate (PIP, a precursor of PIP,). DAG, on the other hand, is either phosphorylated to phosphatidic acid and finally converted back to phospholipids or it is deacetylated to arachidonic acid (a precursor of prostaglandins). Ca" is removed from the cytoplasm by calcium pump through active transport. The Ca" phosphoinositide and cAMP signaling pathways oppose each other in some cells, while they are complementary in others. Thus, vasopressor agents, that contract the smooth muscle, act by IP 3 mediated Ca" mobilisation, whereas agents that relax smooth muscles often act by elevation of cAMP. In contrast, cAMP and phosphoinositide second messengers complement each other to stimulate glucose release from the liver. Ion Channel Regulation. G-protein coupled receptors can control the functioning of ion channels (e.g. K' and Ca" channels) by mechanisms that do not involve any role of second messengers (e.g. cAMP or inostitol phosphate). For example, in cardiac muscle, muscarinic ACh receptors are known to enhance K' permeability (thus hyperpolarising the cells and inhibiting electrical activity). Opioid analgesics also reduce neuronal excitability by opening K' channels by this mechanism. Calcium ion (the third messenger) Ca2+ participates in many functions regulation, such as contraction of muscle, release of neurotransmitters, and secretion of gland etc. The concentration
106 of cytoplasmic Ca2+ can be elevated by calcium influx from the extracellular fluid and by release of Ca2+ from internal storage vesicles. Type III: These receptors are directly linked to tyrosine kinase ies intrinsic catalytic domain (e.g. receptors for insulin and various growth factors) or to guanylate cyclase (e.g. receptors for atrial natriuretic peptide) rarely to serine/theronine protein kinase or bind to JAK (janus kinase) enzyme on activation (lack intrinsic catalytic domain) The agonist binding to the extracellular domain of these receptors produces a conformational change that results in dimerisation and activation of the intracelluar enzyme domaine As a result; the receptor is autophosphorylated thus activating the receptor tyrosine kinase activity towards intracellular signaling proteins. Due to tyrosine phosphoiylation of these proteins, their function is altered which results in a series of events, culminating in the responses like mediating the actions of a variety of growth factors, Those with guanylate cyclase activity results in the formation of second messenger cGMP like for the ANP receptors. The JAK-STAT kinase binding type type III receptors differ from others in that they lack intrinsic catalytic domain The agonist binding to the extracellular domain of these receptors produces a conformational change that results in dimerisation and increases the affinity for cytosolic tyrosine protein kinase, JAK on binding JAK gets activated and phophorylate tyrosine residue of \the receptor which now binds to another freely moving protein STAT (a pair) (signal trasducer activator of transcription)and phophorylated by JAK the pair of phopholylated STAT dimerise and traslocate to the nucleus to regulate gene transcription it is a slow process say take few minutes to hours 4. Type IV: cytosolic receptors for steroid hormones, thyroid hormones and vitamin D. These receptors are cytosolic compartment but precisely speaking these are confined to the nucleus. The agonist (S) (for example, a steroid hormone) first penetrates the cell to combine with the steroid binding site (SBS) of the receptor. This binding then unfolds the receptor and exposes the normally masked DNA-binding site. The agonist receptor complex, with exposed DNA binding site, then associates with DNA of specific gene. This stimulates the RNA polymerase activity and a specified General pharmacology
107 m -RNA is then synthesised. The m-RNA then directs the production of specific proteins (at the ribosomes) required for distinct physiological functions it is slowest of all process say take hours. Receptor Desensitisation Receptor mediated responses to drugs and hormones often 'desensitise' with time. After reaching an initial high level, the response gradually diminishes over seconds or minutes even in the continuing presence of the agonist. This desensitisation is usually reversible which distinguishes it from the "down regulation" of receptors as described below.Many kinds of receptors undergo desensitisation, e.g. at the neuromuscular junction, there is evidence that the desensitisation is caused by a slow conformational change in the receptor resulting in the tight binding of the agonist molecule without opening of the ion channel.(eg succinyl choline) Similarly, adrenoreceptor on desensitisation becomes unable to activate adenylate cyclase, though it can still bind to the agonist molecule. It is believed that the phosphorylation of a single serine residue may be responsible for this process. Up- and Down-regulation of Receptors Prolonged exposure to high concentration of agonist (whether administered as a drug or overproduced as a neurotransmitter) causes a reduction in the number of receptors available for activation (downregulation of receptors). This results due to endocytosis or internalisation of the receptors from the cell surface. On the other hand, prolonged occupation of receptors by a blocker (antagonist) leads to an increase in the number of receptors (up-regulation) with subsequent increase in receptor sensitivity. This probably results due to externalisation of the receptors out again from inside of the cell surface. Sometimes, other hormones can also bring about up-regulation of certain receptors. For example, in thyrotoxicosis, the thyroid hormones bring about up-regulation of receptors on cardiac muscle which increases cardiac sensitivity to catecholamines leading to tachycardia. Significance of Up- and Down-regulation of Receptors Down-regulation of receptors may be responsible for diminished effects seen in severe asthmatics who no
longer respond to 2 adrenoceptor agonist, like salbutamol.
108
In endogenous depression there is down-regulation of -adrenoceptors (with concomitant up-regulation of -
adrenoceptors); and the prolonged use of tricyclic antidepressants results in down regulation of receptors (with relatively up-regulation of -receptors). Potentially disastrous withdrawal effects can result when the administration of an agonist drug is suddenly discontinued. For example, clonidine (a drug whose , adrenoceptor agonist action lowers blood pressure) produces hypertensive crisis after its sudden withdrawal; because the drug during the process down-regulates the receptors which now vigrously respond to the sudden release of catecholamines after the withdrawal of the drug. Hence the phenomenon of down- and up-regulation of receptors may make it dangerous to withdraw certain drugs. In such cases, a gradual tapering of the doses of the drug becomes necessary along with careful watch for the symptoms of the withdrawal reactions. Denervation Supersensitivity of Receptors In denervated muscles, the new receptors are synthesised and these then proliferate all along the cell surface or membrane surface. A similar proliferation of new receptors can occur if these are subjected to prolonged blockade by any antagonist. Such receptors, show supersensitivity to even small amounts of the neurotransmitter being made available despite receptor blockade or due to some active collateral innervation. The pharmacological basis of tardive dyskinesia (excessive involuntary orobuccal- lingual motions; a side effect of neuroleptics after prolonged use) is explained on the basis of supersensitivity of dopamine receptors. Due to long term dopamine receptor blockade by a neuroleptic drug, the striatal nerve cells start synthesising new dopamine receptors which are supersensitive to even small amounts of dopamine still coming through the neurones after neuroleptic blockade. This supersenstitive response causes the dopaminergic inputs to outweigh the cholinergic inputs and thus the patient exhibits the abovementioned excessive movements which are dramatically opposite to parkinsonism. Spare Receptors (receptor reserve) Spare receptors:Drugs may produce its therapeutic effect without occupying all the receptors. These unoccupied receptors are called spare receptors or reserve receptors. Not all the receptors of a cell or a tissue must be occupied in order to provide a maximal response by the drug. That means, each tissue or a cell has a receptor reserve (or spare receptors). As more and
109 more Ach receptors are blocked by the addition of toxin, the amplitude of the muscle twitch, in response to Ach, is not diminished until about 50% of the receptors become occupied by the toxin.That means, at least 50% of the receptors were spare in the sense that they were not required for complet normal twitch by acetylcholine. Myocardium is also supposed to contain a large population of spare receptors because the maximal ionotropic response (FQ to catecholamines can be elicited even when only less than 10% of receptors are occupied) Drug action through placebo action (placebo concept). Placebo ( Latin: I shall please) is a pharmacologically inert and harmless substance given in the grab of a medicine. Or these are the dosage forms which resemble the actual medicament exactly in odor, size, shape, color and weigh that are used to relive the subjective symptoms associated with psychological problems like anxiety, headache, pain, insomnia etc and not at all useful in objective reasons. The effects of placebos are not manifested via psychological approach depending on the patients faith on the prescriber. Placebos have been used in clinical trials in double blind cross over technique to avoid the personal bias of the investigator to avoid positive or negative conclusions. (Nocebo effect: (Latin nocebo = "I shall harm") The recipients of the inert substance /real medicine may nullify the effect intended by simply having a negative attitude towards the effectiveness of the substance prescribed, which often leads to a nocebo effect, which is not caused by the substance, but due to other factors, such as the patient's mentality towards his or her ability to get well, or even purely coincidental worsening of symptoms.) Drugs acts through formation of antibodies and thus stimulate the defense mechanism of the body.e.g Vaccines (BCG vaccine)
110 Chapter IX ADVERSE DRUG REACTION As per WHO, Any noxious, unintended, undesired effect of a drug which occurs at doses used for prophylaxis, diagnosis, or therapy, excluding therapeutic failures, intentional and accidental overdose and drug abuse, and does not include AEs due to errors in drug administration. The onset of an adverse drug reaction can be: 1. 2. 3. Acute: within 1 hour Subacute: between 1 and 24hrs Latent: more than 2 days The severity of an adverse drug reaction can be: 1. 2. 3. Mild: requiring no change in therapy Moderate: requires a change or addition to the therapy. Patients are hospitalised. Severe: disabling or life threatening. It can prolong hospitalisation, result in
congenital abnormalities and requires serious intervention to prevent injury. Causes / predisposing factors 1. 2. 3. 4. The Patient factor The Drug factor The Prescriber factor The Environment factor 1. The patient factors: Patients age, Genetic constitution, and disease state. Age: Neonates, Infants, and elderly persons (65 and above age group are considered as elderly) are more sensitive to the effects of drugs than adult.
111 Neonates: In Neonates and particularly in premature babies hepatic microsomal enzymes (glucuronyl transferase, acetyl transferase) have low activity compared with those in the adult. These enzymes take 8 weeks or longer to reach the adult level of activity. Grey baby syndrome caused by the antibiotic Chloramphenicol was proved to be due to accumulation of very high concentration of Chloramphenicol because of slow hepatic conjugation. Elderly: The activity of hepatic microsomal enzymes declines slowly (and very variably) with age. So they are less capable of metabolizing drugs than the adult patients. The steadily increasing t1/2 of the anxiolytic drug, diazepam is one example. In elderly persons drug metabolism and excretion may be reduced so there are chances of more adverse effects if the dose is not properly adjusted. Elderly people consume more drugs so the potential for drug interactions is increased. Genetic factors: Patients are genetically heterogeneous. Genetic factors play important role in modifying drug action. Adverse drug effects are related to acetylator status, glucose-6-phosphate states etc. Acetylator status: Acetylation is an important conjugation reaction. Many drugs such as sulphonomide, Isoniazid are metabolized by acetylation. If the acetylation is slow (slow acetylator states) some drugs will be slowly metabolized and therefore thre are more chances of adverse effect of that drug. GL-6 PD states: In G-6 PD deficiency haemolysis may occur if persons are exposed to certain drugs like: Primaquine, Sulphonamide, Nalidixic acid. Disease condition: Liver and Renal diseases affect drug bio-transformation and excretion so adverse drug reactions may occur. 2: The Drug factor: Some drug such as anticancer drugs by their nature is cytotoxic. Some drugs e.g. Digoxins has low margin of safety and small increments of dose are more likely to induce dose related adverse effects. pharmacology Other drugs e. g. antimicrobials have General
112 a tendency to cause allergy and may lead to unpredictable adverse effects. Ingredients of a formulation may cause adverse reactions. Commonly used ingredients are: Coloring agents: Fast green, Brilliant blue, Erythrosine.
Flavouring agents: Peppermint oil, Menthol, Orange flavour. Sodium content: Diluent: Nacl Starch, Lactose, Sucrose3. The Prescriber factor
: Prescribers are responsible in the following ways : 3. The Prescriber factor: Prescribing a drug for inappropriately long term use e.g. Prolong use of NSAIDs may cause kidney damage
Prescribing at a critical phase of pregnancy.e.g In first trimester of pregnancy many drug produce teratogenic effect because that is the time of organogenesis. Abrupt discontinuation of some drug may produce adverse effect .e.g Abrupt discontinuation of insufficiency. Prescribing with other drugs resulting in drug interactions e.g If Gentamicin is given along with potent ototoxicity. 4. The Environment factor: Industrial insecticides, pesticides ( DDT), Sunlight( ultraviolet rays ), etc may affect drug bio-transformation causing adverse drug effects. Tetracycline , Nalidixic acid, Sulphonomides etc are phototoxic chemicals. Phototoxic and photo allergic reactions occur due to absorption of radiation by some drugs and conversion of drugs to potent allergens. diuretics (Furosemide) then there are more chances of steroid may produce adverse effects due to adrenocortical
113 The new DOTS scheme is being used to classify adverse drug reactions. This is Dose, Time, and Susceptibility.
114 There are 5 different types of adverse drug reaction: Type A: Augmented Pharmacological Effects Causes an extension of pharmacological effect Usually only occurs in an overdose Responsible for at least two-thirds of ADRs EXPECTED UNDESIRABLE EFFECTS (TYPE A-ADRS) Side Effects These are undesirable effects which are observed even with the therapeutic doses of the drug and are usually mild and manageable.For example: Dicylomine (an anticholinergic drug) relieves pain of intestinal colic due to its antispasmodic action (desirable effect) but side by-side also causes dryness of mouth even in its therapeutic doses (side effect). Similarly, promethazine (an antihistaminic drug) has antiallergic action (desirable effect), but it also produces sedation in therapeutic doses (side effect). Several drugs produce epigastric distress as their side effect. However, proper adjustment of the dose (in previous cases) or use of counter measures, like antacids (in epigastric distress) usually ameliorates the symptoms of side effect. Secondary EffectsThese are indirect consequences of the main pharmacodynamic action of the drug.For example: Development of super infection after suppression of bacterial flora by antibiotics and weakening of host defenses after the use of corticosteroids. As above, these effects may occur even when the drug is used in therapeutic dose but can be predicted from the pharmacological profile of the drug. Toxicity These are exaggerated form of side effects which occur predictably either due to overdoses. The reason could be pharmacodynamic (e.g. bleeding due to high doses of heparin or coma due to high doses of barbiturates) or pharmacokinetic (e.g. crystaluria or glomerular nephritis due to precipitation of sulfonamides in acidic urine or nephrotoxicity due to gentamicin in cases having renal insufficiency). Certain drugs in high doses may cause poisoning, e.g. delirium, hyperpyrexia, and hallucinations with overdoses of atropine (atropine poisoning; a pharmacodynamic reason). Type B: Bizarre Effects Idiosyncratic or immunogenic response General pharmacology
115 Cause immune response
116 Normally unpredictable includes allergy and pseudoallergy UNEXPECTED UNDESIRABLE EFFECTS (Type B-ADRs) These arise unexpectedly, even when the drug is used in therapeutic doses, by a mechanism unrelated to the main pharmacological effect of tie drug. These include, either immunologically mediated reaction to the drug, or pharmacogenetically mediated adverse response or idiosyncratic reaction due to peculiarities of anindividual for which no definite genotype has been described. These are grouped as unpredictable responses because firstly, there is no linear relationship with drug doses, and secondly, the predictive tests, if any, are uncertain, expensive and unpracticable. Drug Allergy (Hypersensitivity Reactions) Allergic responses to drug occur when there has been previous exposure to drug (or its metabolites) and when this sensitised individual is reexposed to the same drug again. It is loosely termed also as hypersensitivity. During the first uneventful exposure, the drug (or its metabolite) acts as hapten which, after combining with host proteins, becomes antigenic. Specific antibodies are formed against this antigen which keep on circulating. On re-exposure there is then antigen -antibody response which results in the release of the chemical mediators of allergy (histamine, 5 HT, leucotrienes, SRS-A and PAF etc.) causing effects like urticaria, rhinitis, pruritis, asthma, and anaphylactic shock (exaggerated and immediate type of hypersensitivity characterised by hypotensive shock, bronchoconstriction, angioneurotic edema, laryngospasm followed by death) Drugs may elicit following types of allergy Type I (immediate type). Allergy develops within minutes and lasts for 2-3 hr. The drug causes formation of tissue sensitising IgE antibodies that are fixed to mast cells or leucocytes. The subsequent exposure to drug degranulates mast cells and activates leucocytes with release of chemical mediators of allergy. The patient, if untreated, suddenly passes into anaphylactic shockType II (auto or accelerated allergy). It occurs within 72 hr. of drug administration. The drug (or its metabolite) combines with host proteins and converts them to antigen. The body thus treats them as foreign proteins and forms antibodies (IgG and IgM) against them. On re-exposure, with the same drug, an antigen-antibody reaction takes place which activates complement and damages the cells. Manifestations include fever, lupus erythematosus, and hemolysis and thrombocytopenia etc. Type III (delayed allergy). It occurs after 72 hr but within 1-2 weeks of drug administration.
117 Antigen antibody (predominantly IgG) form complexes which are deposited on vascular endothelium and activate complement. It is characterised by allergic inflammatory reactions in tissues, glomerular nephritis and serum sickness. Type IV (cell mediated allergy). Here antigen specific receptors are developed on Tlymphocytes, which when activated after subsequent exposure with the drug, leads to local or tissue allergic reactions (photo sensiti sation and contact dermititig). Cross Allergy. The cross allergy within the members of the same group of drugs is most common. Why allergy is very common with some drugs, like penicillins and why the same drug does not cause allergy in all individuals is not exactly clear.Desensitisation can be attempted in some limited cases only Idiosyncratic Drug ResponsesThese are harmful and sometimes fatal reactions that occur in a small minority of individuals, for which the cause is yet poorly understood. A few examples can be cited:1) A condition of malignant hyperpyrexia, a dangerous idiosyncratic reaction to drugs like halothane, succinyl choline and neuroleptic drugs, like chlorpromazine and haloperidol. It is supposed to be an inherited trait, though the exact basis is not yet known.Occurrence of aplastic anemia with a single dose or with low doses of chloramphenicol is in approximately 1:50,000 patients. This idiosyncratic effect is believed to be related to the presence of para-NO 2 group in chloramphenicol structure because thiamphenicol (which contains a para-SO 2 CH 3 group instead of p-NO 2 ) has the least risk, but at the same time is lesser active than chloramphenicol. Till date, it is only a conjecture without proof.Aspirin induced late onset asthma or chronic renal failure and thiazide diuretics induced erectile impotence are some other examples of idiosyncratic reaction due to drugs.
118 Some examples of type A and type B reactions Drug Type A reaction Ampicillin Chlorpromazine Naproxen Practolol Thiazides Warfarin Type C: Chronic Effects Associated with long-term use Involves dose accumulation Methotrexate is stored by the liver. Transaminase liver enzyme levels Pseudomembranous colitis Sedation Gastrointestinal hemorrhage Bradycardia Gout Bleeding
Type B reaction Interstitial nephritis Hepatotoxicity Agranulocytosis Oculomucocutaneous syndrome Thrombocytopenia Breast necrosis
may rise for a few days after treatment but they quickly return to normal and the next dose may be taken safely. Long term therapy for two years or more may cause scarring (fibrosis or cirrhosis) of the liver. Chronic administration of chloroquine for the treatment of rheumatoid arthritis has revealed an ocular toxicity due to accumulation of the drug in the pigmented layers of the eye, particularly the choroids. Type D: Delayed Effects Delayed effects (sometimes dose independent) Carcinogenicity (e.g. immunosuppressants) Teratogenicity: the capacity of adrug to cause foetal abnormalities when administered to pergnent woman e.g thalidomide induced phocomelia and phenytoin induced microcephali (foetal hydantoin syndrome). A teratogenic drug can affect the foetus in 3 stages of its developments 1) during 17 days of conception affecting fertilization and implantation of the fertilise ovum leading to failure of pregnancy which is usullay unnoticed. 2) during organogenesis (18-55 days of gestation) resulting in deformities like phocomelia, 3) during 56 day onwards resulting in functional abnormalities like NSAIDs causes premature closure of ductus arteriosus.
119 Teratogenic adverse effects: Harmful effect on the foetus within the uterus resulting in a malformed child is known as teratogenic effect and the drug is called teratogenic drug (Greek teratos=Moster, genesis= production). Drugs may act on the embyo and fetus & they may affect directly or indirectly. Cytotoxic drugs, antithyroid drugs affect directly. Uterine Vaso constrictors may reduce blood supply to uterus and cause fetal anoxia and teratogenicity .Adverse effect of drug may be observed due to administration of drug during any time of pregnancy and labour. Early pregnancy A single intrauterenine exposure to a drug can affect the fetal structures undergoing rapid development at the time of exposure. Cytotoxic drugs, Antithyroid drugs, Tetracyclines, sulphonylureas etc has been grouped as positive teratogenic drugs. In fact no drug is safe if used during early pregnancy The most vulnerable period is 4-10 weeks after LMP because during this time organogenesis occurs. Drugs known to be teratogenic include: Cytotoxics, Warfarin, Lithium, Methotrexate, Phenytoin, Valproate, ACE inhibitors Many drugs have come under suspicion. The subject is highly emotional for prospective parents. Late pregnancy After the organs are formed abnormalities are less anatomically dramatic. In late pregnancy adminidtration of hormones, androgens or progestogens can cause fetal masculinisation. Iodide and antithyroid drugs in high dose can cause fetal goiter.Tetracyclines can interfere with tooth and bone development. ACE inhibitors are associated with renal tubular dysgenesis and a skull ossification defect. If psychotropic drugs are used during pregnancy abnormal behavioural effects may be observed due to impaired development of central nervous system. General pharmacology
120 During Labour Any drug that acts to depress respiration (Opioid analgesics) in the mother may cause respiratory depression in the new born. General anesthetics may cause fetal distress by reducing uterine blood flow. Detection of teratogenesis: Retrospective (Case-controll) study. To suspect any abnormality to be drug induced then detail drug history of the mother to be recorded. Registration of all birth defects to be maintained at different level for retrospective study. Classification of teratogenic drugs: Positive teratogenic drugs; If taken pregnancy should be terminated. Androgens: Virilism, cardiac defects Tetracyclines: Discolouration & deformed teeth, Retarded bone growth, organ malformation. Methotrexate: Multiple defects. Warfarin: Nose, eye, and hand defects Possible teratogenic drugs Indomethacin Antithyroid drugs Phenytoin Suspected teratogenic drugs Trimethoprim,
121 Carcinogenic effects: Some drugs may produce bone marrow depression resulting in fatal leukemia. Example: Chloramphenicol, it may cause aplastic anemia. The anticancer drugs may give rise to second malignancy. Prolong modification of cellular mechanisms can lead to permanent change in structure and function leading to carcinogenicity thus H2 blockers and proton pump inhibitors may produce carcinoid tumours Type- E (Ending of use) Abrupt discontinuation of drugs may give rise to adverse effects. ExamplesRebound adrenocortical insufficiency due to sudden withdrawal of steroids. SPECIFIC TOXICITY OF SOMEPARTICULAR DRUGS Toxic effects of drugs can be: (a) related to their principal pharmacological action, e.g. hypoglycaemic coma with insulin, bleeding with anticoagulant drugs, and arrhythmias with cardiac glycosides or (b) unrelated to their principal pharmacological action. The latter are specific toxicities with some particular drugs.Such toxicities often involve a chemically reactive metabolite (rather than the parent drug) and are at times immunological in nature also. Examples include liver or kidney damage, bone marrow suppression, carcinogenesis and teratogenesis (impaired foetal development). Such effects, which are liable to occur with any kind of chemical or a drug, fall conventionally into the area of toxicology rather than pharmacology. Type E: End of Treatment Effects 1. 2. 3. 4. 5. 6. 7. Withdrawal reactions Opiates, benzodiazepines, corticosteroids Rebound reactions Clonidine, beta-blockers, corticosteroids Adaptive reactions Neuroleptics (major tranquillisers) There is also a new proposed type F for (Failure of therapy).
122 Iatrogenic disease (drug-induced diseases): A drug prescribed for a disease causes another disease as aspirin- induced asthma and peptic ulcer or phenothiazines induced Parkinsonism.
123 How to avoid 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. First the drug should always be administered at the lowest dose that produces acceptable benefits, Adjunctive drugs that act through different receptor mechanism and produce different toxicities may allow Drug must be administered through the most appropriate route to get selectivity of effect. Diagnosis of drug allergy: If patient is allergic to a drug, it is better that they should never come into contact Drug to be prescribed in right dose and for right duration, in right dosage form. Genetic predisposition of patient to be considered. Abrupt discontinuation to be avoided to drugs like steroid B-Blockers. Drug with low Therapeutic index-monitoring in plasma is required. Different stages of pregnancy and lactation should be carefully considered and drugs should be avoided accordingly. In elderly special precautions to be taken as there may be multiple pathology, decrease in Liver, Renal, Patients personality, attitude to disease, occupation, mode of life style, relationship with doctors etc also Sometimes drug holidays are also required.
recognizing that complete abolition of sign or the symptoms of disease may not be achieved. lowering the dose of the first drug.
with it. In some special cases, hyposensitization / desensitization can be done under cover of a corticosteroid.
Cardiac and pulmonary functions. contributes drug tolerance vis-a-vis adverse effect. So this side must not be overlooked.
124 Chapter X HOW DRUG EFFECTS CAN BE MEASURED

(THE QUANTITATIVE ASPECTS OF DRUG EFFECTS/ DOSE RESPONE RELATION SHIP)
WHAT IS A DOSE It is the required amount of drug in weight, volume, moles or international units that is necessary to provide a desired effect. In clinical practice it is called as a therapeutic dose, while for experimental purposes (in animals) it is called as an effective dose. The therapeutic dose varies from person to person and from one clinical situation to the other and hence is indicated by a range. For example: the dose of aspirin to provide relief from pain is 300 mg to 1 g wherein 300 mg is the minimum dose while 1 g is the maximum dose which can be given to an individual for different analgesic purposes. The drugs can be administered as: Single Dose It is the quantity of a drug to be administered all at once For example, a single oral dose of piperazine (4-5 g) is sufficient to eradicate round worms or a single IM dose of 250 mg of ceftriaxone can be given to treat gonorrohea. Daily Dose It is the quantity of a drug to be administered in 24 hr, either all at once or in equally divided doses (the dose interval is decided on the basis of the plasma half life along with other parameters, like aVd as discussed earlier). For example, 10 mg daily dose (all at once) of cetrizine is sufficient to relieve allergic manifestations; while a daily dose of erythromycin (an antibiotic) is 1 g per day to be given in 4 equally divided doses (i.e. 250 mg every 6 hr). Dose Total It is the maximum quantity of the drug that is needed during the complete course of the therapy. For example, the total dose of procaine penicillin for the treatment of early syphilis is 6 million units and this is given as 0.6 million units per day for 10 days.
125 Loading Dose (Priming Dose) Loading dose is one or series of doses that may be given at onset of therapy to achieve target concentration quickly.Loading dose may be desirable if time required to attain steady state concentration by the administration of drug at constant rate is long relative to demands of the condition being treated. For example half-life of Lignocaine is one hour. Arrhythmias following myocardial infarction are usually rapidly fatal, and one can not wait for 46 hours to achieve therapeutic concentration of lignocaine by infusion of drug at the rate required to maintain this concentration. Therefore loading dose of Lignocaine is usually given in coronary care unit. Disadvantages of loading dose:Patient may be exposed abruptly to toxic concentration of a drug.If drug has long half-life, it will take long time for the concentration to fall, if plasma level of drug is high.Loading dose is usually given intravenously, this is particularly dangerous if loading dose is large and drug is administered rapidly. Maintenance Dose. In most clinical conditions, drugs are administered in a series of repetitive doses or as a continuous infusion in order to maintain a steady state concentration of the drug in the body i.e. just enough drug is given in each dose to replace the drug eliminated since the preceding doseTherefore calculation of maintenance dose is essential.To maintain a chosen target concentration (Css), rate of drug input (maintenance dose) is equal to rate of drug clearance. Pediatric dose: Because of the differences in pharmacokinetics in infants and children, they require small doses as compared to adults. The approximation of pediatric doses can be made by methods based on age, weight and surface area. These approximations are not precise and should not be used if manufacturer provides a pediatric dose. Fatal dose: Amount of dose that causes death of 100% of experimental animal. Toxic dose: Dose that causes signs and symptoms of drug toxicity. MIC90: MIC means minimum inhibitory concentration. MIC90 is the concentration at which 90% susceptible microorganisms are inhibited by the antimicrobials
126 Test dose: Amount of drug given initially before given full therapeutic dose , to observe the response is called test dose. Booster dose: An additional dose of an immunizing agent to increase the protection afforded by the original series of administration.
MEASUREMENT OF DRUG EFFECTS After giving a dose, the drug effects can be measured for quantitative assessment of its safety and efficacy. For quantitative assessment of drug effect need few variables like the dose, the plasma concentration, the isolated tissue or the whole subject or the population on which the response is to be measured and of course the response itself. For plotting any curve and to derive quantitative information, must have three variables: One independent variable to be plotted on X-axis (abscissa), the other dependent variable to be plotted on Y-axis (ordinate) and the third, a constant variable, which being common, can be eliminated and therefore not shown on the graph. Thus for the dose-plasma concentration curve doses are plotted on abscissa (independent variable) versus plasma concentration on ordinate (dependent variable), eliminating the subject to whom the doses were administered (constant variable). Alternatively, time-plasma concentration curve can be plotted by using time on abscissa (independent variable) versus plasma concentration on ordinate (dependent variable), ignoring the subject in whom plasma concentrations were measured at different time intervals after giving a particular dose (constant variable). Hence can depict the relationship between different doses (graded doses) and their relative response by plotting the graded doses (independent variable) on abscissa versus the relative plasma concentrations (dependent variable) on the ordinate, eliminating the isolated tissue or the single subject (constant factor) to whom the doses were administered. The graphic curve thus obtained is called as the graded dose -response curve; Alternatively, eliminate the response either by quantifying it or by prefixing its criteria on "all or none" basis (i.e. death or no death, anaesthesia or no anaesthesia or by quantification like "25% rise in pulse rate from the basal value"). Thereafter can obtain a curve by plotting doses (independent General pharmacology
127 variable) on abscissa versus the number of subjects providing this "prefixed" response (dependent variable) on ordinate.
128 Obviously, the response, being quantified or prefixed on "all or none" basis, is a constant factor common to all subjects. The curve, so obtained, is classified as "quantal dose-response curve". All these relationships are merely the graphic representations of mathematical expressions. GRADED DOSE-RESPONSE CURVES The graded dose-response curves are obtained by administering increasing amounts of the drug to a single subject or to an isolated tissue. When the doses (in arithmetic scale) are plotted on abscissa, against the per cent response, as the dose is increased, the magnitude of response also increases until a stage comes when a further increase in the dose elicits no further increase in the effect. The response at this stage is called as the "maximal response (MR)" or the ceiling response( due to the complete saturation of receptor) while the corresponding dose is called as the "maximal dose (MD)" or the ceiling dose. The graphic representation of such simple graded dose-response curve takes the form of a hyperbola.
% MR r e s p o n s e
0.1
0.2
0.4
0.8
1.6(MD)
Dose in g/ml Limitation of a Simple Graded Dose-Response Curve The initial portion of the curve is so steep that it is virtually impossible to guage the magnitude of increase in the response corresponding to the small increase in the doses. Precisely speaking, when the effect is approaching a maximum, large increments in dose produce such changes in response which are actually too small to be evaluated with accuracy. On arithmetic scale, it is extremely difficult to display a dose range in which the largest dose is several times that of the smallest. As a result, the huddling together of so many doses is inevitable or else an unusually wider graph paper would be needed to accommodate all these doses. General pharmacology
129 LOG DOSE-RESPONSE CURVES On the logarithmic scale, it may be noted that although each selected dose (0.1, 0.2, 0.4, 0.8 and 1.6 g/ml) is just the double of its preceding dose, the interval between their log values is equal (1.0, 1.3, 1.6, 1.9 and 0.2, i.e. having a constant interval of 0.3) because the logarithmic transformation has the property of turning multiplication into addition (i.e. x 2 to + 0.3)
1.0
1.3
100 (MR) % R e s 50 p o n s e
ED50 1.6 Log dose
(MD)1.9
Now one can have a wider range of doses on a smaller and yet single graph paper. Furthermore, the hyperbolic simple graded dose-response curve now gets compressed and takes the shape of a sigmoid curve (S-shaped curve), in which the middle portion of the curve is almost a straight line. The top most portion of the curve represents the "maximal response (MR)" while the lower most portion depicts that these doses are almost ineffective. The effect of increasing doses of histamine causing muscle contraction of guinea pig ileum and of acetylcholine causing contraction of frog rectus muscle are some examples where such log doseresponse relationships could be obtained.
130 Information Derived From Log Dose-response Curves i) From the middle porition of the curve (i.e. the linear segment) one can find out the ED50 of a drug. The ED 50 means effective dose required to produce 50% of the maximal desired response.Smaller the ED50 more potent is the drug.( ED1 dose required to produce 1% of the maximal desired response and ED99 dose required to produce 99% of the maximal desired response). ii) Frequently, two drugs produce the same effect by the same mechanism. In such cases the LDR curves of both the drugs run parallel to each other and among them the LDR curve of the less potent drug would be located on the right side, on the dose axis.
MR 100 99 % R e s p o 50 n s e
ED50A ED99
ED50B ED99
Log dose
For example, let us assume that drug A and drug B are producing the same effect by the same mechanism and drug B is half as potent as drug A. Then, in comparison, the reponse obtained by any dose of drug A would match with the response obtained with twice the dose of drug B. Therefore, all the corresponding points on the LDR curves of both the drugs will remain equally spaced, while the points on the curve of weaker drug B, will always lie equally spaced towards the right side of the curve for drug A.
131 Converse is also true, i.e. two drugs that act by different mechanism will have a non parallel LDR curve though heve similar response quatitatively. The location od LDR curve on the X axis also indicates the affinity of the drug to the receptor. The drug with more affinity for the receptor will be located near to Y axis and vice versa. That is the drug A has more affinity for the receptor that drug B lDR curves also helps to differentiate between the potency and efficacy of a drug Potency is a measure of drug activity expressed in terms of the amount required to produce an effect of given intensity. While efficacy, refers to the maximum response achievable from a drug refers to the maximum response that can be elicited by a drug,. The potency of a drug is reflected by the position of the LDR curve while efficacy by the height of the LDR curve.see the fig. below. The drug with more potency will be located near to Y axis and vice versa that is the order of potency will be A>B>C and the EC50 of these drug will have the same order. while the drug will more efficacy will have more height ies more maximum response at low dose ies the order of efficacy will be A>B>C.
A B C
100 (MR) % R e s p o 50 n s e ED50A Log dose
ED50B
ED50C
132 QUANTAL DOSE RESPONSE CURVE A graphic curve obtained by plotting different doses on X axis and the number of subjects producing a prefixed response (on all or none basis) on Y axis is known as quantal dose response curve. A simplified and arbitrary example is given below. The extract containing digitalis (standard or unknown) is infused into the vein of the anaesthetised cats at the rate of 1 ml/min till the heart stops and the blood pressure falls to zero level. 50 cats were used for the study. The dose and the number of cats shown cardiac arrest are given in the table.
10
4 10
No. Of Cats Shown Cardiac Arrest
2 20
30
40
50
12
20
30
38 44
Dose /ml/min
48
133 The dose in ml/min Number of cats shown cardiac arrest Total Number of cats shown cardiac arrest 10 15 20 25 30 35 40 45 50 2 4 6 8 10 8 6 4 2 2 (2+4)6* (6+6)12 (12+8)20 (20+10)30 (30+8)38 (38+6)44 (44+4)48 (48+2)50
* since 2 cats already responded to the 10ml/min dose they would respond to the higher doses also hence the total number of cats shown cardiac arrest is 6. This observed data can be displaed on a bar diagram as follows: which illustrates the frequency distribution of these subjects to digoxin induce cardiac arrest.
134 After joining the mid points of these bars and drawing aline a bell shaped curve is obtained known as normal frequency curve.
B No. Of Cats Shown Cardiac Arrest
12
20
30
38 50 44
10
20
30
48
40
50
No. Of Cats Shown Cardiac Arrest
A Dose /ml/min
Dose /ml/min
From the area covered by the curve three portions are obtained A a small number of subjects who are highly sensitive and respond to smaller doses. B the maximum number of subjects respond to this dose range C small number of subjects who least sensitive and respond to higher doses Limitations of normal frequency curve. Lack of informations like ED50 and LD50 This difficulty can be over come by plotting the percentage of subjects responding vs log dose.
135
1%
Information Derived From Quantal Dose-Response Curves Form LDR curves, from the middle linear segment of the curve, one can find out ED50 effective dose required to produce 50% of the maximal desired response. When mortality studies are done, from the middle linear segment of the LDR curves, one can find out LD50, median lethal dose required to produce death in 50% of the population.( LD1 dose required to produce death in 1% of the population and LD 100 dose required to produce death in 100% of the population) THERAPEUTIC INDEX (TI) It is the ratio of median lethal dose (LD50) to median effective dose (ED50).OR it is the measurement that describes the relationship between doses of drugs required to produce undesired and desired effects. LD50 TI = ED50 Therapeutic index is used to evaluate safety and usefulness of a drug, higher the therapeutic index safer will be drug. For safe application of a drug its therapeutic index should be more than one. Penicillins and benzodiazepines have high therapeutic index.Digitalis, general.Anesthetics and Anticancer drugs have low therapeutic index.Depending upon therapeutic utility, a drug may have more than one therapeutic indices.Ideally a drug should have LD50 much higher than ED50.
100%
The percen tage of 50% Subjec ts respon ding
Log dose
0 0 1
L D
L D
L D
136 STANDARD MARGIN OF SAFETY (SMF): Therapeutic index may be misleading if the log dose response curve for effectiveness and toxicity have different slopes i.e. are not parallel. Therefore, standard margin of safety may be more useful. Standard margin of safety shows the percentage by which ED99 (Dose effective in 99% of population) must be increased to cause toxic effects in 1% of population. Greater the percentage of SSM, safer is the drug. Formula for standard margin of safety is:
LD1-ED99 SMF = ED99 CERTAIN SAFETY FACTOR (CSF) X100
The aim of drug therapy is to achieve the desired therapeutic effect in all individuals without the risk of producing a hazardous effect if any. The therapeutic index described as above provides only an approximation of the relative safety. The drug safety, however, can be better assessed by having the ratio derived from the extremes of the respective quantal response curves, i.e. by finding out the ratio between the dose effective in 99% of the subjects (ED99) and the dose which is lethal to 1% of the subjects (LD). This ratio is called as the Certain Safety Factor (CSF). LD1 CSF = ED99 CSF more than one indicates that lesser amount of the dose is effective in 99% of population with respect to what would be lethal to 1% of the population. A CSF value of less than one means an overlap between the ED99 and LD1 indicating that the drug is unsafe for therapeutic use. THERAPEUTIC WINDOW The frequency distribution diagram reveals that the same dose regimen produces a low plasma concentration or insufficient response in others (A)or a high plasma concentration and toxicity in some patients (C)while In between, there is an optimal therapeutic range of plasma concentrations at which most of the patients experience the desired effects(B) This optimal therapeutic range of General pharmacology
137 plasma concentrations of the drug is called its Therapeutic window. The exact pharmacological basis of this is not yet clearly understood but may be due to dual or complex action of the drug
138 Let us take the example of digoxin having a therapeutic window in between a plasma concentration of 0.9-1.5ng/ml ( a norrow therapeutic index) below of which the the drug is clinically not effective in many of the subjects and a plasma concentration above it is found to be clinically unsafe. (see fig. below) other drugs showing therapeutic window phenomenon are Lithium (0.16-1.2 mEq/L), Phenytoin(10-20 pg/ml), Quinidine (2-6 gg/ml), Theophylline (5-20 g/ml) etc.
Sub optimal
Optimal
Toxic
Frequency (No. Of Subjects Responding)
Therapeutic window
0.9
1.2
1.5
Plama conc: in ng/ml of digoxin
PROLONGATION OF DRUG ACTION It is sometimes advantageous to modify a drug in such a way that it acts for a longer period. Methods utilized for prolonging drug action are summarized below: 1. 2. 3. 4. By prolonging absorption from site of administration Oral: Sustained release tablets: Drug particles are coated with resins, plastic materials, or other substances. Parenteral: The subcutaneous and intramuscular injection of drug in insoluble form can provide for its Examples are: Benzathine penicillin, Lente insulin, Depot progesins, pellet implantations
Sometimes semi permeable membrane are used to control the release of drug from the dosage formulations absorption over a couple of days to several months or even years.
139 5.
Transdermal drug delivery system: The drug impregnated in adhesive patches, strips or as ointment applied
on skin is becoming popular 6. By increasing plasma protein binding: Drug congeners have been prepared which are highly bound to plasma protein and are slowly released in the free active form. Example: Sulfadoxine 7. By retarding rate of metabolism: Small chemical modification can markedly affect the rate of metabolism without affecting the biological action. Example: Addition of ethinyl group to estradiol makes it longer acting and suitable for use as oral contraceptive. Inhibition of specific enzyme by one drug can prolong the action of another drug. Example: Cilastin protects Imipenem from degradation in kidney 8. By retarding renal excretion: The tubular secretion of drug being an active process can be suppressed by a competing substance. Example: Probenecid prolongs duration of action of penicillin.
140 Chapter XI BIOASSAY OF DRUGS BIOASSAY Estimation of the concentration or potency of a substance by measurement of biological response produced by it on the biological systems (i.e. observation of pharmacological effects on living tissues, microorganisms or immune cells or animal) is known as biological assay or bioassay. Microbiological assay, radioimmunoassay assay is also regarded as 'bioassay'. In this method, one of the main pharmacological effects of the drug under test is compared with that of the standard drug or preparation and their potency ratios are then compared quantitatively. For example: The unknown preparation having acetylcholine like action is compared with standard solution of acetylcholine by measuring the contractile responses on frog rectus abdominus muscle. Analogously, histamine like preparations are compared with histamine for their contractile responses on isolated guinea pig ileum. The bioassay methods are usually applied: To measure the pharmacological activity of new or chemically undefined substances; To measure the concentration of known substance (e.g. acetylcholine, histamine, serotonin or catecholamine) in a tissue extract or body fluids; To measure ED 50 or LD50 of a drug; For biological -standardisation of drugs from d) natural sources which cannot be obtained in a chemically pure form, e.g. vasopressin, oxytocin, insulin and heparin. PRINCIPLES OF BIOASSAY The bioassay usually involves the comparison of the main pharmacological response of the unknown preparation with that of the standard. The best kind of standard, of course, is the pure substance; but at times it is often necessary to utilise the standardised preparations of General pharmacology
141 hormones or natural products against which the unknown sample can be calibrated, even though the standard preparation used is not chemically pure. The reference standard and the test sample should have similar pharmacological effects and should have the same mode of action, so that their LDR curves run parallel and their potency ratios can be conveniently compared. The test solution and the reference standard should be compared for their established pharmacological effect using a specified pharmacological technique, e.g. acetylcholine and histamine can be compared with their respective test samples for their contractile responses on frog rectus abdominus muscle or isolated guinea pig ileum, respectively; adrenaline and its related test sample for the rise in blood pressure in dogs or cats, and so on. However, some exceptions can be made, e.g. insulin preparations should ideally be assayed by estimating blood sugar levels, but, for the sake of convenience, the most commonly used method is the comparison of hypoglycaemic convulsions in mice. The methods selected should be reliable, sensitive, reproducible, and should minimise errors due to biological variations and methodology. Hence, the animals used should always be of the same species, sex and weight and if an isolated preparation is used, it should be sensitive. The number of animals should be large enough to permit statistical analysis and the experimental conditions should always be kept constant. Methods of Bioassay for Agonists An agonist may produce graded response or quantal response. Graded response means that the response is proportional to the dose and response may lie between no response and the maximum response. By quantal, it is meant that the response is in the form of "all or none", i.e. either no response or maximum response. The drugs producing quantal effect can be bioassayed by end point method. The drugs producing graded responses can be bioassayed by (1) Matching or bracketing method or (2) Graphical method (interpolation method & multiple point methods).
142 End Point Method or quantal assay By quantal, it is meant that the response is in the form of "all or none", i.e. either no response or maximum response. The drugs producing quantal effect can be bioassayed by end point method. Here the threshold dose producing a positive effect is measured on each animal and the comparison between the average results of two groups of animals (one receiving standard and other the test) is done. For example, bioassay of digitalis in cats, here the cat is anaesthetized and its blood pressure is recorded. The drug is slowly infused into the animal and the moment the heart stops beating and blood pressure falls to zero, the volume of fluid infused is noted down. Two series of such experiments - one using standard digitalis and other using test preparation of digitalis is done and then potency is calculated as follows:form the following graph take the antilog values of X and Y and their ration is multiplied by the conc of the standard drug.
Std
Test
TD50
TD 50
100 Cumulative %. Of Cats Showning 50 Cardiac Arrest
X Log dose
143 Threshold dose of std. Conc. of Unknown = Threshold dose of test X Conc. of std.
In case, if it is not possible to measure individual effective dose or if animals are not available, fixed doses are injected into groups of animals and the percentage of mortality at each dose level is determined. The percentage of mortality is taken as the response and then the comparison is done in the same way as done for graded response. Other examples are insulin induced "hypoglycaemic convulsions" in mice; "head drop" assay for d-tubocurarme in rabbits Matching Method In this method a constant dose of the test is bracketed by varying doses of standard till the exact match is obtained between test dose and the standard dose. Initially, two responses of the standard are taken. The doses are adjusted such that one is giving response of approximately 20% and other 70% of the maximum. The response of unknown which lies between two responses of standard dose is taken. The panel is repeated by increasing or decreasing the doses of standard till all three equal responses are obtained. The dose of test sample is kept constant. At the end, a response of the double dose of the standard and test which match each other are taken. These should give equal responses. Concentration of the test sample can be determined as follows; Maching dose of std. Maching dose of test X Conc. of std.
Conc. of Unknown = =
144 This method has following limitations It occupies a larger area of the drum as far as tracings are concerned. The match is purely subjective, so chances of error are there and one cannot determine them. It does not give any idea of dose-response relationship. However, this method is particularly useful if the sensitivity of the preparation is not stable and the test sample is too small. Bioassay of histamine, on guinea pig ileum is preferably carried out by this method. Bracketing Assay It is also used when the test sample is too small. The observed response with the test drug is bracketed between the one higher and one lower response of the standard. The strength of the unknown can be found by simple interpolation of this bracketed response on the dose axis. Graphical method This method is based on the assumption of the dose-response relationship. Log-dose-response curve is plotted and the dose of standard producing the same response as produced by the test sample is directly read from the graph. All the three methods described above are not reliable because they do not take into account (a) changes in the sensitivity of the tissue with respect to time, (b) the timing of the doses, (c) variations in the mode of application of drugs, and are based on the application of a single dose (or few doses) and hence cannot be subjected to statistical evaluation. In simpler design, 5-6 responses of the graded doses of the standard are taken and then two equiactive responses of the test sample are taken. The height of contraction is measured and plotted against the log-dose. The dose of standard producing the same response as produced by the test is read directly from the graph and the concentration of test sample is determined by the same formula as mentioned before. The characteristic of log-dose response curve is that it is linear in the middle (20-80%). Thus, the comparison should be done within this range only. In other words, the response of test sample must lie within this range.
145 Advantage of this method is that, it is a simple method and chances of errors are less if the sensitivity of the preparation is not changed. Interpolation method: It is based on the principles of LDR curves discussed earlier. In this method, the LDR curve of the standard drug is obtained first. Later two or three such responses of the unknown (T1, T2, T3), which fall in between the linear portion of the LDR curve, are obtained by trial and error. Then, by interpolation of these responses at the dose axis, and taking the antilog (ofX,Y&Z), the concentration of the unknown test solution can be found.
Std T T 23 Reponse T 1
XYZ Log dose
146 Multiple Point Assays Other methods which are based on the dose-response relationship include 3 point, 4 point, 5 point and 6 point methods. In these methods the responses are repeated several times and the mean of each is taken. Thus chances of error are minimized in these methods. In 3 point assay method 2 doses of the standard and one dose of the test are used. In 4 point method 2 doses of standard and 2 doses of the test are used. In 6 point method 3 doses of standard and 3 doses of the test are used. Similarly one can design 8 point method also. The sequence of responses is followed as per the Latin square method of randomization in order to avoid any bias. The mean responses are calculated and plotted against log-dose and amount of standard producing the same esponse as produced by the test is determined graphically as well as mathematically Three-point Assay ( 2 + 1 dose assay). This is a faster bioassay procedure having general utility. The steps are discussed by taking an example of bioassay of acetylcholine in some tissue homogenate. First of all, a LDR curve is plotted with varying concentrations (doses) of the standard Ach solution. The doses are plotted in log scale (on X-axis). Two such doses (s1 and s2) are then selected whose respones (S1and S2) lie in between the linear part of this LDR curve. Care should be observed in selecting these doses so that their concentrations are in simple ratio (e.g. 2, as in 1:2 or 2:4 ratio), since its log value has to be used in the calculations. Subsequently, a dose (t) of the test sample, which produces a response (T), in between S, and S2, is found. Bioassay is then performed in four sets using three doses (s I , s2 and t), in a randomised fashion, in each set, e.g. using s1, s2, t/ s2, t, s1 and t, s1, s2 (one can observe from the latin square design so that none of the sequence is repeated, i.e. the doses have been randomised to avoid error). The respective mean responses (of these four sets) are then plotted on the graph paper and mathematically computed to find out the strength of the test solution. Conc of Unknown = {[s1 / t] Antilog [{(T-S1)/ (S2-S1)} log (s2/s1)]} X Conc of Std
147 Procedure Record the graded dose response curve of standard histamine on guinea pig ileum as described in earlier. Record the graded dose response curve of test sample of histamine in the same manner by taking 0.1, 0.2, 0.4, 0.8, 1.6 ml of test sample of histamine Select two dose of standard histamine (i.e. s1 and s2) whose responses (S1 and S2) lie in between the linear part (i.e. 30-70%) of log dose response curve [care should be observed in selecting these doses so that their concentration in the ration of 1:2; since its log value has to be used in the calculation, i.e. s1 / s2=2] Subsequently select a dose of the test sample of histamine (t), which produces a response (T), which lies in between S1 and S2. Record the responses of s1, s2 and t in a randomized fashion in 3 sets (i.e. s1, s2, t ; s2, t, s1; t, s1, s2.) Calculate the average of response height of s1, s2 and t (S1, S2 and T) Concentration of the unknown solution of histamine can be calculated by using the formula. Conc of Unknown = {[s1 / t] Antilog [{(T-S1)/ (S2-S1)} log (s2/s1)]}X Conc of Std s1 = Lower standard dose in ml, s2 = Higher standard dose in ml, t = Test dose in ml S1 = Response of s1 in cm, S2 = Response of s2in cm, T = Response of t in cm Four-point Assay (2+2 dose assay). This type of bioassay, though cumbersome, provides fairly accurate results. First of all, the log dose-response curves for both the standard and the test solution are constructed as described above. Two doses of the standard (s1and s2) and two such doses of the test solution (t1and t22) are selected whose respective responses (S1, S 2 and T1, T2) fall within the linear portion of their LDR curves, respectively. In selecting these doses care should be taken so that the responses due to the lower doses of the standard (S1) and the test solution (T1) and due to the higher doses of the standard (S2) and General pharmacology
148 the test solution (T2) should be similar amongst themselves. Furthermore, the ratio between the higher and the lower doses of the standard (i.e. s1/s2) and of the test solution (i.e. t1t2,) should not only be the same but simpler too (e.g. s2/S, = t2/t, = 2, as in 1:2 or 2:4) because their log values are to be used in calculations.Four sets of bioassay are then performed using 4 doses s1and s2/ t1and t22 in a randomised fashion, in each set (i.e. 4 x 4= 16 doses). Each set could use doses in a sequence, like s1, s2/ t1, t2 /s2, t1, t2, s1/ t1, t2, s1, s2 and t2, s1, s2, t1. Six-point Assay (3 + 3 dose assay). The reliability of this bioassay is excellent but it is too time consuming, and hence lesser in use. It differs from the 4-point assay (2+2 dose assay) in the sense that here three concentrations of the standard and 3 concentrations of the test substance are used in six sets of experiments using six doses in each set (i.e. 6 x 6 = 36 doses) in the randomised fashion as discussed above.
149 Bioassay of Antagonists Commonly used method for the bioassay of antagonist is simple graphical method. The responses are determined in the form of the percentage inhibition of the fixed dose of agonist. These are then plotted against the log dose of the antagonist and the concentration of unknown is determined by finding out the amount of standard producing the same effect as produced by the test. In this method, two responses of the same dose of agonist (submaximal giving approximately 80% of the maximum response) are taken. The minimum dose of standard antagonist is added in the bath and then the response of the same dose of agonist is taken in presence of antagonist. The responses of agonist are repeated every ten min till recovery is obtained. The higher dose of standard antagonist is added and responses are taken as before. Three to four doses of the standard antagonist are used and then one to two doses of test sample of the antagonist is used similarly. The percentage inhibition is calculated, plotted against log dose of antagonist and the concentration of unknown is determined as usual.
Bioassay of Some Important Drugs Depending upon pharmacological action of various drugs, different preparations may be used. Following chart gives different preparations and the pharmacological activity for which a particular drug is assayed:
Drugs Digitalis Preparation Cat blood pressure Guinea pig blood pressure Pigeon Blood pressure of the spinal cat Isolated rabbit duodenum, Isolated caecum of fowl, Noradrenaline Acetylcholine Isolated rat uterus Blood pressure of the pithed cat Isolated rectus abdominis muscle of frog, rat ileum and leech dorsal muscle Isolated mouse heart Inhibition of cardiac contractions Rise in B.P. Contractile effect. Activity Assayed Fall in B.P. and death Stoppage of heart and death. Emesis Rise in B.P. Inhibition of the tone
Adrenaline
150
Histamine Rat/Cat blood pressure Isolated, atropinized terminal ileum of guinea pig. Anaesthetized and atropinized cat. 5 Hydroxytryptamine Isolated atropinized rat uterus, Isolated terminal colon of rat, Isolated fundus strip of rat stomach, Perfused rabbit ear " Constriction of blood vessels Curariform drugs, e.g. d-tubocurarine Heparin Rabbit Rat diaphragm with phrenic nerve, Cat gastrocnemius muscle with sciatic nerve. Sulfated whole blood of ox with thrombokinase extract and acetone dried ox brain Antibiotics Suitable microorganism grown on suitable nutrient agar medium Vitamin D Insulin Rats maintained on richetogenic diet Rabbits Mice Isolated rat diaphragm Rat's epididymal fat Inhibition of growth of micro-organism Alleviation of rachitic stage. Lowering of blood-sugar level. Convulsions and/or death due to hypoglycemia Increase in glycogen content. Increased metabolism of glucose, indicated by increased in CO2 Oxytocin Adult cockerel Isolated rat uterus Rabbits (female) production. Vasodepressor activity. Contractile effect Ejection of milk from mammary duct. Dropping of head Inhibition of the contractile effect Prolongation of blood clotting time Fall in blood pressure Contractile effect " Fall in blood pressure Contractile effect
151 Chapter XII FACTORS INFLUENCING DOSAGE AND DRUG RESPONSE The term called DOSAGE which literally means "the method of dosing". The science that deals with the study of dosage of medicines is reffered to us the POSOLOGYand the dosage depends on following factors: 1. 2. 3. 4. The dosage form and the amount of the drug to be administered at one time The route of administration The interval between doses The duration for which the drug administration is to be continued. For example: Cap Amoxicillin 500 mg, to be taken at 8 hourly, for 5 days is the usual dosage for a case of upper respiratract infection. Factors influencing dosage and drug response are the following: 1. 2. 3. 4. Variations in the response to the same dose of a drug between different patients and even in the same The range of variability is more marked with drugs disposed by metabolism than with drugs excreted The dose of drug is generally expressed in the range, which gives therapeutic effect in majority of patients. The dose range usually based on the average requirements of an adult and is not strictly applicable under
patient on different occasions have been observed. unchanged in urine.
all circumstances. Important factors modifying drug action in an individual which necessitate an adjustment in dosage are the following; BODY WEIGHT / SIZE AGE SEX ENVIRONMENTAL FACTORS ROUTE OF DRUG ADMINISTRATION TIME OF DRUG ADMINISTRATION General pharmacology
152
GENETIC FACTORS EMOTIONAL FACTORSAGE, BODY WEIGHT, BODY SURFACE AREA, SEX. An average adult dose of a drug is calculated on the basis of the quantity that will produce a desired effect in 50% of population between 18 to 65 years of age and weighing about 70 kg. But in special cases of pharmacokinetic variations that leads to variation in drug response is encoundered in relation to dosage in children of different age and in case of abnormally lean and obese patients. Hence the dosage has to be adjusted in such case due to difference in age, body weight & body surface area. AGE: Pharmacokinetics of many drugs change with age, metabolizing capacity of liver is low and renal function is less well developed in newborn. In old age both hepatic and renal function decline. Children and old age persons generally require low dose than adults as the incidence of side effects is higher at the extremes of age. Glomerular filtration rate reaches the adult rate by 5th month and tubular secretion by 7th month. Blood brain barrier is more permeable in infants leading to the accumulation of drug in brain. Children are growing and are susceptible to special adverse effects of drugs, for example Suppression of growth with corticosteroids; Androgens promote epiphyseal fusion and result in short stature. Solid forms of drug and aerosols are difficult to administer to children. BODY WEIGHT / BODY SIZE: Average dose of a drug is mentioned in terms of mg/Kg body weight. However, the dose mentioned may not be applicable to all cases.
153 In abnormally obese or lean person individuals dose adjustments must also take in to account the changes in the ratio of body water to body mass since it vary significantly compared to normal population. In cases of edema weight of patient increases due to the accumulation of ECF and in malnutrition metabolizing capacity of drug is reduced, these factors should be kept in mind while calculating the dose of drug. The difficulty can be over come by calculation the dose based on body surface area. For this purpose various formulae are available to calculate the dose as per age/ body weight/ body surface area. Because of the differences in pharmacokinetics in infants and children, they require small doses as compared to adults. The approximation of pediatric doses can be made by methods based on age, weight and surface area. These approximations are not precise and should not be used if manufacturer provides a pediatric dose. YOUNGS RULE: applicable for children below 12 yrs of age. Age of child Pediatric dose = Age + 12 X adult dose
FRIED RULE: Based on age in months Age (in months) Pediatric dose = 150 X adult dose
CLARKS RULE: Based on body weight Wt. of the child (lb) Pediatric dose = 150 Wt. of the child (kg) Pediatric dose = 70 BASED ON BODY SURFACE AREA (BSA) X adult dose X adult dose (70kg=150lb) OR
154 BSA (in sq. m) Pediatric dose = 1.8 PERCENTAGE OF ADULTS DOSE TO BE ADMINISTERED TO A CHILD = (1.5 Xwt in kg) + 10 OR (0.7 Xwt in lb) + 10 Sex Drug response may not be always same in men and women for which there is no satisfactory answer and hence considered as idiosyncrasy or paradoxical drug responses. For e.g Barbiturate a sedative and hypnotic drug may produce CNS stimulation in women before sedation, which is not encountered in men. Ketoconazole an antifungal dtrug causes loss of libido in men and not in women. But these effects are appearing to be of minor consequences and may not require the dosage adjustments but the difference in pharmacokinetics of drug like in case of menstruation, pregnancy and lactation may require the dosage adjustments in women. Females have smaller body size and require doses that are on lower side of the range. In women consideration must be given to menstruation, pregnancy and lactation. Drugs given during pregnancy may affect the fetus(teratogenicity) Marked Physiological changes occur during pregnancy that can alter the drug disposition. For example G.I.T motility is decreased that results in delayed absorption of drug, plasma protein concentration and consequently binding of drug to proteins is increased during pregnancy, enzyme induction is observed and renal blood flow increases that cause rapid elimination of drug. The overall effect on drug disposition is complex and difficult to predict; drugs should carefully be given during pregnancy. X adult dose (BSA= W 0.425(kg) X H 0.725(cm) X 0.00718 )
155 A number of drugs like clonidine, methyldopa, and blockers interfere with sexual function in males but not in females. Gynecomastia produced by drugs like Digitalis, Cimetidine,
156 Ketoconazole, Metochlopramide, Spironolactone and Chlorpromazine occur in males not in females. During pregnancy the growth of the uterus, placenta and fetus increases the volume available for distribution of drug, while the albumin level falls and 1 acidic glycoprotein level increase affecting the distribution and response of drugs. But most important is to avoid teratogenic drugs during pregnancy. Difference in races :Drug action may vary between races For example, Negros are tolerant to mydriatic action of a sympathomimetics, like ephedrine. Eskimos can tolerate high fatty diets without any clinical consequence while Chinese are tolerant to the purgative action of castor oil.Quin iodochlor an antiamoebic drug caused Subacute myelo-optic neuropathy is an iatrogenic disease of the nervous system leading to a disabling paralysis, blindness and even death. Its defining manifestation was as an epidemic in Japan during the 1960s, but Indian population is tollerent to this drug. ENVIRONMENTAL FACTORS: Drug metabolism is slow at high altitude due to oxygen deficiency. Cigarette smokers and industrial workers exposed to some pesticides metabolize drugs rapidly due to enzyme induction. ROUTE OF DRUG ADMINISTRATION: Route of drug administration governs the speed and intensity of drug response. In general, intravenous dose of drug is usually smaller than oral, and time of onset of action is quick with intravenous route. A drug may have entirely different uses through different routes. For example Magnesium sulfate given orally produce purgation, applied locally on inflamed area decreases the swelling while intravenously it produces CNS depression and hypotension. Oxytocin on Iv infusion is used to induse labour while IM for postpartum haemorrhage while intranasally for breast engorgement. General pharmacology
157 GENETIC FACTORS: The dose of a drug to produce same effects may vary 46 folds among different individuals. This is mainly due to the differing rates of drug metabolism as the amount of microsomal enzymes is genetically controlled. There are some specific genetic defects that lead to variation in drug response. Example;Hemolysis by Primaquine and Sulfonamides in persons with G.6.P.D. deficiency, seen mainly in American negros.Prolonged apnea by Succinylcholine in patients with atypical psudocholinesterase.Slow metabolism of Isoniazid, Procainamide and Hydralazine in slow acetylators. EMOTIONAL FACTORS: Personality of physician and patient may influence the effects of drug. Sometimes inert dosage forms can relieve the symptoms this is called PLACEBOa Latin word means I SHALL PLEASE. Placebos are pharmacodynamicaly inert and harmless substance given in the grab (impression) of a medicine. Pacebos are a type of dosage form resembles the actual medicine in physical characteristics like size, shape, odour, color and weight.It works by psychological rather than pharmacological effects and often produces response equivalent to the actual drug. Placebo is used to compare the therapeutic effects of various drugs during therapeutic trials of the drugs. Personality of patient also affects the drug response, nervous and anxious patients require more general anesthetics than normal persons do. Placebo resembles the actual medicine in physical characteristics. Placebo can be given orally as well as parenterally. It does not produce drug drug interactions.
158 Placebo is used to compare the therapeutic effects of various drugs during therapeutic trials of the drugs. Substances used as placebo are lactose, distilled water and dextrose. While NOCEBO a Latin word means Iwill harm is opposite to placebo and the symptoms of illness donot respond to the medicinein case of nocebo reactors METABOLIC DISTURBANCES: Changes in water and electrolyte balance body temperature and acid base balance may modify the effects of drug. For example aspirin reduces body temperature only in presence of fever and have no effect on body temperature when it is normal. Iron is well absorbed in states of iron deficiency. Vasoconstrictor effect of norepinephrine is reduced in presence of metabolic acidosis. Low acidity decreases iron (Fe) absorption. PATHOLOGICAL STATES OR PRESENCE OF DISEASE: Not only drugs modify the pathological process, but also several diseases influence the drug disposition and drug action. Hepatic, renal and cardiovascular diseases have important influence on drug clearance and drug actions. Drugs must be carefully used in presence of diseases of these organsIn coeliac disease, the absorption amoxicillin is decreased while that of cephalexin and cotrimoxazole is increased. Bioavailability of drugs having first pass metabolism increases causing toxicity in liver diseases while decreses ( therapeutic failure) for drugs which are activated by metabolism (prodrgs). In patients with impaired renal functions, like streptomycin, gentamicin and kanamycin which are exxcreated unchanged in urine can cause toxicity (ototoxicity) due to its accumulation in the body as result of decresed excreation of the drug
159 Chapter XIII MODIFIED DRUG EFFECTS AFTER REPEATED ADMINISTRATION OF A SINGLE DRUG The conyinous administration of adrug can affect the action of the same drug in many ways they are the following
Drug Tolerance Tolerance is characterised by the need to increase the dose of a drug in order to produce the phacological response of equal magnitude as that of the initial doses. In other words it is an inability of the subsequent administration of the same dose of the same drug, to be as effective as its initial dose. Graphically, the log dose- response of a tolerant person shows a shift towards right side because higher than initial doses are required to achieve the same effect.
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Log dose General pharmacology
160 Tolerance is a common phenomenon seen usually with CNS active drugs, like morphine alcohol, barbiturates. LSD and amphetamine etc. it is not necessary that tolerance would develop uniformly to all pharmacological effects of a drug. For example, tolerance develops to all pharmacological effects of morphine (to varying degrees) except for miosis and constipation. Similarly tolerance develops to the sedative actions of chlorpromazine and phenobarbitone but not to their respective antipsychotic and antiepileptic effects. The tolerance developed to CNS active drugs is frequently associated with either psychological or physical dependence Reverse Tolerance (or sensitisation ) which is also observed with an intermittent dosing schedule but is opposite to the phenomenon of tolerance. With reverse Tolerance there is a left ward shift of the log dose-response curve, that is a greater response than seen after the initial dose. For example, after repeated daily administration of a dose of cocaine or amphetamine in rats, there is a gradual increase in their motor activity even though the dose remains constant.
Innate tolerence is the genetically determined lack of sensitivity to a drug.(inherited) e.g. negros are tolerent to the mydriatic action of sympathomimetics while Chinese are tolerant to the purgative action of castor oil
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Log dose General pharmacology
161 Cross tolerance: It is the development of tolerance to pharmacologically related drugs, e.g. alcoholic need relatively large doses of barbiturates, as they are tolerant to this class of drugs. Closer the drugs are, more complete is the cross-tolerance between them; e.g. there is partial tolerance between morphine and barbiturates but complete cross-tolerance between morphine and pethidine. Acquired Tolerance This is seen by repeated use of a drug in an individual who was initially responsive This type of tolerance is not inherent, rather is acquired at a later stage after repeated administration of the drug. The acquired tolerance can result due to either pharmacokinetic or Pharmacodynamic reasons. The tolerance developing through the first mechanism is called as drug disposition (or metabolic) tolerance, and that by second mechanism is called as cellular adaptive or target tissue or pharmacodynamic tolerance. 1. Drug Disposition or Metabolic Tolerance. This type of tolerance may occur when a drug reduces its own absorption or increases its own metabolism through microsomal enzyme induction The net result is the decrease in the effective concentration of the drug-at the site of action. The log plasma concentration-response curve of the tolerant person would exhibit no change when compared with that of the normal a person, because the excess doses taken by the tolerant person are simply compensating for the losses incurred due to faster drug disposition
-
The examples of pharmacokinetic tolerance resulting due to increase in the rate of biotransformation
through enzyme induction are barbiturates, gluthetimide and meprobamate (refer enzyme induction) 2. Cellular Adaptive (target tissue or pharmacodynamic) Tolerance. This type of tolerance may be attributed to some kind of adaptive changes that have taken place (1) (2) drug induced changes in the receptor density (down-regulation) impairment in receptor coupling to signal transduction pathways.
162 In a person showing a pharmacodynamic type of tolerance with a drug, the log plasma concentrationresponse curve a right ward sift because, after repetitive dosing, although the plasma concentrations are rising, yet there is no proportionate rise in the drug response Tachyphylaxis (Acute Tolerance) IT describes the acute development of tolerance after a rapid and repeated administration of a drug at shorter intervals. It may result primarily due to any of the following reasons: Gradual depletion of the agonist from the storage sites with no chances of its replenishment because of the repeated administration of the drug at short intervals. example, tachyphylaxis seen with ndirectly acting sympathomimetics like eshedrine, amphetamine and tyramine.which acts by releasing catecholamines (from the storage sites), the synthesis of which is unable to match with its release. Hence, further response decreases due to nonavailability of adequate stores of catecholamines. Tachyphylaxis may also occur as a result of a change in the sensitivity of target cells (pharmacodynamic reason). For example, tachyphylaxis to nitroglycerine is observed among workers exposed to this drug in its manufacturing industry.on Monday or Tuesday, these workers suffer severe headache which gradually disappears by Friday due to the development of tolerence. After enjoying their weekend on Saturday and Sunday when they return to their job on Monday, the headache reappears (Monday disease) Difference between tachyphylaxis and tolerance: Tachyphylaxis is rarely seen in clinical practice since repeated-administration, of drugs at short intervals is not customary-,, in therapy. Tolerance, on the other hand, is observed clinically. Tachyphylaxis develops faster while Toleance develops slowly In tolerance, the original effect of the drug can still be obtained by increasing the dose which is not possible. in tachyphylaxis
163 Drug Resistance It refers to unresponsiveness of microorganisms to an antimicrobial agent after its repeated use and is similar to the phenomenon of tolerance seen in higher organisms. The drug resistance could be of two types: Natural Resistance Some micro-organisms have always been resistant to certain antibiotics, e.g. Gram negative bacilli are normally unaffected by penicillin-G This type of resistance poses no significant clinical problem as only the proper drugs which are effective against the particular micro-organisms are usually selected. Acquired Resistance It is the development of resistance by an organism (which was initially sensitive) due the use of an antimicrobial agent over a period of time. For example, the past 20 years, highly penicillin resistant gonococci have emerged. This type of resistance develops by gene transfer (conjugation, transduction or transformation) or by mutation. Cross Resistance If a micro-organism resistant to one antimicrobial agent exhibits resistance to another antimicrobial drug belonging to the same category (to which the organism was not exposed earlier). it is called as cross resistancelor example,a micro-organism becoming resistant to penicillin may exhibits resistance to all -lactam antibiotics, unrelated drugs also exhibit partial cross resistance, e.g. a micro-organism resistant to erythromycin exhibits resistance to lincomycin, Drug Allergy Allergy is an adverse, unexpected response to the usual therapeutic doses of a drug resulting from a previous exposure tothe same substance e.g penicillins Cumulation
164 Cumulation occurs when the rate of removal or inactivation of a drug is slower than the rate of its administration Such a phenomenon can lead to dangerous overdosage and toxicity. Cumulation is
165 more likely when the drug has a long half life (e.g. digoxin, chloroquine) but may also be associated with certain highly lipid soluble drugs having shorter duration of action(thiopental), due to its redistribution to tissues and fat receiving lesser blood supply. The retinal toxicity resulting after prolonged use of chloroquine is a result of its cumulative toxicity. MODIFIED DRUG EFFECTS AFTER CONCURRENT ADMINISTRATION OF TWO DIFFERENT DRUGS It refers to a condition where the administration of one drug with another drug results in the modification of the action of any one or the both drugs. Summation is defined as the combined action of two drugs administered together which acts by different mechanism will be equal to the algebraic sum of the individual effect of the drugs ies 1+1=2
Aspirin
Morphine
Inhibit prostaglandin synthesis
Acts via opioid receptors
Analgesia
Analgesia
Double analgesic effect
166 Additive Effects is defined as the combined action of two drugs administered together which acts by same mechanism will be equal to the algebraic sum of the individual effect of the drugs ies 1+1=2
Aspirin
Paracetamol
Analgesia
Analgesia
Double analgesic effect Synergism is defined as the combined action of two drugs administered together will be greater than the algebraic sum of the individual effect of the drugs which may be a potensiation of the action or prolongation of the effect.ies 1+1>2 It may result when two two drugs act at different sites (1)or one drug alter the pharmacokinetics of the other(2).
167 (1) Trimethoprim Sulfamethoxazole
Inhibit dihydropteroate synthase enzyme and inhibit folic acid synthesis
Inhibit dihydro folate reductase and inhibit folic acid synthesis
Bacteriostatic
Bacteriostatic
Bactericidal (2) Levodopa
Metabolized by peripheral decarboxilase enzyme and reduce the central bioavailability of levo dopa and causes peripheral side effects
Carbidopa inhibits the peripheral decarboxilase enzyme
On combination of these two the central bioavailability of levo dopa increases and reduce the peripheral side effects
168 Drug Antagonism is defined as the combined action of two drugs administered together is less than the algebraic sum of the individual effect of the drugs ies1+1<2 There are four mechanisms by which one drug may oppose the action of another, and these are: Chemical Antagonism When the drugs act merely as chemical antidotes to each other. The drugs reacts chemically to inactivate each other. e.g. Heparin (strong acid) and Protamine (strong base) the antidote for heparin overdosage. BAL/EDTA as heavy metal chelating agents for heavy metal poisoning. Physiological or Functional Antagonism The two agonists acts at two diiferents sites to produce opposite effect on the same physiological system, but each drug is unhindered in its ability to elicit its own response. e.g. insulin and glucogon, CNS stimulants like srychinine and CNS depressants like barbiturate. Biological orPharniacokineticAntagonism When one drug affects the absorption, metabo lism or excretion of the other and effectively reduces the concentration of the active drug at its site of action. For example: (i) reduction of anticoagulant effect of warfarin in presence of an enzyme inducer like phenobarbitone which accelerates its metabolism; (ii) urinary alkalisers like sod. bicarbonate and sod. dihydrogen citrate increase the urinary excretion of acidic drugs (by increasing their ionisation and preventing th ei r tubular reabs orp ti on (used in the management of poisoning due to salicylates and barbiturates). Pharmacological Antagonism It is a pharmacodynamic antagonism between two drugs acting on the same receptor (i.e. an antagonism through receptor blockade). As stated earlier, antagonists bind to the receptor or to the components of the effector mechanism, to inhibit -the action of agoinst but these themselves are General pharmacology
169 devoid of intrinsic regtlatory-activity.) It involves two important mechanisms according to which these antagonists are classified as acting reversibly or irreversibly. 1. Reversible (or competitive or surmountable or equilibrium type) Antagonism. In this type of antagonism the antagonist binds to the same site on the receptor where the agonist binds and prevents the binding of the agonist but itself unable to activate the receptor. Both the drug compete with one another for the binding site on the recptor.(competitive) This type of inhibition can be overcome by increasing the concentration of the agonist. Maximal response can be still achieved with higher concentrations of the agonist. (Surmountable antagonism).
This LDR graph shows the rightward shift of the LDR curve of the agonist with increasing dose of the antagonist and agonist The log dose-response curves for the agonist show a rightward parallel shift in the presence of a competitive antagonist
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ED50 ED50 ED50 Log dose (agonist) General pharmacology
170 The agonist in presence of a competitive antagonist appears simply to be lesspotent and its ED 50 are higher in the presence of the reversible antagonist These characteristics reflect that the reversible antagonist dissociates faster from the receptor sites and hence the addition of higher concentration of the agonist reduces the rate of its association with the receptor sites by occupying the available spare receptors Consequently, the antagonist occupancy falls and a new equilibrium is rapidly established (hence the term equillibrium type of antagonism). The duralion of competitive blockade is short due to the higher rate of dissociation of the antagonist molecule from its reneptor sites. Example atropine is a competitive antagonist of acetylcholine at muscarinic receptors; propranolol is a competitive antagonist of noradrenaline at - receptorsand naloxone competitively antagonises the effects of opioids (morphine) at opioid receptors. Irreversible (non-equilibrium type) Antagonism. In this type of antagonism the antagonist binds to the same site on the receptor irreversibly where the agonist binds and prevents the binding of the agonist irreversibly but itself unable to activate the receptor. It involves the covalent binding of the antagonist to the receptor. Both the drug compete with one another for the binding site on the recptor.(competitive) The antagonist dissociates very slowly or not at all from the receptors hence this type of inhibition cannot be overcome by increasing the concentration of the agonist Maximal response cannot be achieved with higher concentrations of the agonist. (Insurmountable antagonism)
171
(This LDR graph shows the effect of increasing dose of the antagonist on LDR curve of the agonist). Log dose-response curves of the agonist reflect reduced eifficacy but unaltered potency The duration of action of the irreversible antagoinst is longer as the rate of dissociation of irreversible antagonist is very slow. E.g. Organophosphorous compounds bind irreversibly to acetylcholine esterase enzyme and dibenamine is an irreversible -adrenergic receptor antagonist for noradrenalin Pseudoreversible antagonism In this type increasing concentrations of the agoinst, in the presence of such irreversible antagonist will initially shift the LDR curve to the right (similar to reversible one ) producing maximum response (due to the presence of spare receptors) but eventually if the concentration of this irreversible antagonist is increased there will be a reduction in the maximal response (due to reduction in the number of available receptors.
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Log dose (agonist) General pharmacology
172
(This LDR graph shows the effect of increasing dose of the peeudoreversible antagonist on LDR curve of the agonist). Non-competitive Antagonism. In this type of antagonism the antagonist blocks some point in the chain of events resulting in blockade of the agonist action or to a site other than the agonist binding site (allosteric site) causing conformational change in the agonist binding site resulting in blockade of agonist binding to the site and hence the reponse. e.g verapamiI and nifedipine prevent the opening of voltage gated Ca-channels and thus inhibit the Ca entry, associates with depolarisation. These drugs therefore block quite non-sp'ecifically, the contraction of cardiac muscle produced by noradrenaline. Bicuculline binds to the allosteric site on GABA receptor and inhibit the action of diazepam. Negative Antagonism (inverse agonism). : This type of antagonism the receptor is triggered to produce a response in the opposite direction that of a natural physiological signal molecule/ an agonist.. E.g. - carbolines on benzodiazepine receptor.
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Log dose (agonist) General pharmacology
173 Structure-activity relationship (SAR) is the relationship between the chemical or threedimensional structure of a molecule and its biological activity. The analysis of SAR enables the determination of the chemical groups responsible for evoking a target biological effect in the organism. This allows modification of the effect or the potency of a bioactive compound (typically a drug) by changing its chemical structure. Medicinal chemists use the techniques of chemical synthesis to insert new chemical groups into the biomedical compound and test the modifications for their biological effects.This method was refined to build mathematical relationships between the chemical structure and the biological activity, known as quantitative structure-activity relationships (QSAR). A related term is structure affinity relationship (SAFIR). The basic assumption for all molecule based hypotheses is that similar molecules have similar activities. This principle is the basis of Structure-Activity Relationship (SAR). The underlying problem is therefore how to define a small difference on a molecular level, since each kind of activity, e.g. reaction ability, biotransformation ability, solubility, target activity, and so on, might depend on another difference. For example, the replacement of a hydrogen atom with a fluorine atom at a site of metabolic oxidation in a drug candidate may prevent such metabolism from taking place. Because the fluorine atom is similar in size to the hydrogen atom the overall topology of the molecule is not significantly affected, leaving the desired biological activity unaffected. However, with a blocked pathway for metabolism, the drug candidate may have a longer half-life. Procainamide, an amide, has a longer duration of action than Procaine, an ester, because of the isosteric replacement of the ester oxygen with a nitrogen atom. Alloxanthine is an inhibitor of xanthine oxidase. It is also an isostere of Xanthine, the normal substrate for the enzyme.
174 DRUG COMBINATION Simultaneous use of two or more drugs seperately or combination of drugs in a single pharmaceutical formulation. Types: 1. Fixed dose drug combination Its is the combination of two different drus in a single dosage form in fixed doses. e.g Cotrimoxazole=Sulphamethoxazole(400mg) + Trimethoprim(80mg), Fansider= Pyrimethamine(25mg) + Sulphadoxine(500 mg), Sinemet= Levodopa (250 mg) + Carbidopa Basic requirements of the member drugs for such combinations are: 1. 2. They should have approximately equal plasma t1/2 The ratio of combination depends on their apparent volume of distribution(Vd) and peak plasma
concentration at steady state e.g. amoxicillin(t1/2=1-2hr & Vd=0.21L/kg) and clavulanic acid (t1/2=1-1.5hr & Vd=0.20 L/kg) Advantage of Fixed dose drug combination Better patient compliance due to convenience in dose schedule. Synergistic effect of the combination can be exploited.e.g. Cotrimoxazole.(Bactericidal) is a combination of Benefitial effects of combination can be exploited to reduce the side effects e.g 1.the side effects of
two bacteriostatic drugs Sulphamethoxazole & Trimethoprim. Levodopa due to its pheripheral convertion to dopamine by peripheral decarboxylase can be overcome by inhibiting the enzyme using Carbidopa in fixed dose drug combination. 2. Vitamin B-6 with INH Useful in enhancing the availabilityof drug at site of action. The conversion of Levodopa to dopamine by peripheral decarboxylase can be overcome by inhibiting the enzyme using Carbidopa there by enhancing the availabilityof levodopa in the brain. To prevent the developmat of resistence by micro organisms to a single drug or to over come it.e.g. amoxicillin(suseptable to lactamase enzyme produced by various microorganisms) and clavulanic acid ( lactamase inhibitor) General pharmacology
175 Dis Advantage of Fixed dose drug combination Dose adjustments if required are not possible. The differences in pharmacokinetic parameters will result in unacceptable variations in plasmaconcentration Difficult to identify the component drug causing the adverse effect / beneficial effect. Non -fixed dose combination INH + Rifampicin + Ethambutal in pulmonary tuberculosis, Indications of drug combinations are To reduce the toxicity/ adverse effect of an individual drug If patient is sufferring from multiple diseases Some times in undiagnosed but serious illness multiple drugs are used To achieve an additive or synergistic effect- Penocillin + Streptomycin in streptococcal infection To prevent bacterial resistance LIST OF DRUGS BANNED FOR MARKETING IN INDIA 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Fixed dose combinations of crude Ergot preparation except those containing Ergotamine, Caffeine, Fixed dose combinations of Vitamins with Anti TB drugs except combination of Isoniazid with Pyridoxine Fixed dose combinations of Atropine and Analgesic and Antipyretics. Fixed dose combinations of Strychnine and Caffeine in tonics. Fixed dose combinations of Yohimbine and Strychnine with Testosterone and Vitamins. Fixed dose combinations of Iron with Strychnine, Arsenic and Yohimbine. Fixed dose combinations of Sodium Bromide/chloral hydrate with other drugs. Fixed dose combinations of antihistaminic with anti-diarrhoeals. Fixed dose combinations of Penicillin with Sulphonamides. Fixed dose combinations of Vitamins with Analgesics. Fixed dose combinations of Tetracycline with Vitamin C. General pharmacology
of the component drugs.
analgesics, antihistamines for the treatment of migraine, headache. Hydrochloride (Vitamin B6).To counter side efects- Vitamin B-6 with
176
177 Chapter XIII DRUG INTERACTIONS A drug interaction may occur if the effect of a drug is altered by the presence of another drug, food, drink or environmental agent. The main risk factors for clinically significant drug interactions include drugs with a narrow therapeutic index, patients age and genetic characteristics. Clinical importance: All drug interactions are not clinically important. Following reactions are important: Reactions with drugs that have steep dose response curve and a narrow therapeutic index. Drugs that are known enzyme inducers or inhibitors. Reactions with drugs where precise plasma concentration is required e.g Oral contraceptives, Lithium. When several drugs are used at the same time In severely ill patients with multiple pathology Drug-drug interactions The co administration of two or more drugs can affect the pharmacological action of the individual drus in many ways. Drug-Drug Interactions An alteration in the effectiveness or toxicity of one drug due to the action of another simultaneously administered drug is known as drugdrug interaction. Causes of Drug Interactions: Various factors are responsible for the drug interactions. 1.Use of non-Prescription drugs: The simultaneous use of prescription drug with nonprescription drugs (e.g.antacids decongestants,aspirin) 2.Multiple Pharmacological effects: Many drugs used in the therpy have the action on many physiologic systems of body. Therefore when two drugs are administered simulaneously it will affect some of the same systems.
178 3.Multiple Physicians: The patient in a short period visits more than one physician which may result in drug interactions. 4.Patient Noncompliance: Many times patients do not follow the instructions of physician of pharmacist (or patients do not receive the instructions properly regarding medication) 5.Drug abuse : There is a tendency of some patients to abuse or misuse the drugs for quick results, causing drug interaction. Drug interactions may result in: a) b) c) Adverse effects wherein there is a decrease in the effectiveness or an increase in the toxicity of one drug in the Biological interference with laboratory tests which may mislead the diagnosis Beneficial reaction, wherein there is an increase in the effectiveness or a decrease in the toxicity of one drug
presence of the other
in the presence of another. Drug interaction is the modification of the action of one drug by another as a result of one or more of three kinds of mechanism: I II III Pharmaceutic or In-vitro Pharmacodynamic Pharmacokinetic
I. Pharmaceutic interactions. I Pharmaceutic interactions (outside the body or before absorption from the site of administration). These consist of incompatibilities that result in precipitation or inactivation when drugs are mixed. Specific examples are given in Table Interactions outside the body.
179
Mixture Thiopentone + suxamethonium
Result
Precipitation Diazepam + infusion fluids Phenytoin + infusion fluids Soluble insulin + protamine zinc insulin Heparin + hydrocortisone Kanamycin + hydrocortisone Penicillin + hydrocortisone Inactivation of penicillin Inactivation of kanamycin Inactivation of heparin Reduced effect of soluble insulin Precipitation Precipitation
II. Pharmacodynamic interactions. These are the commonest drug interaction in clinical practice. Most have a simple mechanism consisting of summation or opposition of effects of drugs with similar or opposing actions initiated by combination with common or different receptors (reffer the combined drug effects). Since this kind of interaction depends broadly on the effect of drug, rather than on its specific chemical structure, such interactions are non-specific
180 Useful interactions The combination of thiazide diuretics (e.g. Chlorthalidone) with a potassium-sparing diuretic (e.g. Spironolactone) provides an example of drug combinations that are useful to prevent hypokalemia caused by thiazide diuretics Sometimes micro-organisms acquire drug resistance via synthesis of an enzyme that degrades antibiotic (e.g. penicillinase producing staphylococci). This can be overcome by using a combination of the antibiotic with an inhibitor of the enzyme, for example coamoxiclav is a combination of clavulanic acid, an inhibitor of penicillinases with amoxycillin, a semisynthetic penicillin. Clavulanic acid has no antibacterial activity on its own, but by inhibiting penicillinase makes the combination effective against organisms that would be resistant to amoxycillin alone by reason of penicillinase production. These include most Staphylococcus aureus as well as a fraction of Gram-negative organisms such as Escherichia coli, Hemophilus influenzae, Klebsiella and some anaerobes. In some instances, important interactions occur between drugs acting at a common receptor. These interactions are generally useful when used deliberately, for example the use of naloxone to reverse opiate intoxication, or less diretly the reversal of muscular relaxation by tubocurarine by the local increase of acetylcholine caused by cholinesterase inhibition with neostigmine. Use of diuretics to avoid salt and water retention and adrenergic blockers to avoid tachycardia associated with the use of vasodilators for hypertention It is probable that several drugs used in cancer chemotherapy are mutually synergistic. Harmful interactions The coadministration of Non-steroidal anti-inflammatory agents with antihypertensive drug angitensinconverting enzyme inhibitors(ACE)( captopril) render the latter less effective The interaction is probably due to inhibition of biosynthesis of vasodilator prostaglandins which is other wise stimulated indirectly by ACE inhibitors Thus adrenergic blockers and calcium channel blockers, which may safely be given together by mouth in many patients with uncomplicated hypertension or angina pectoris, precipitate heart
181 failure, which may be fatal, if used sequentially intravenously in patients with supraventricular tachycardia. Cardiac status and route of administration are critical. Warfarin interferes with hemostasis by inhibiting the coagulation cascade, whereas aspirin influences hemostasis by inhibiting platelet function. Aspirin also predisposes to gastric bleeding by direct irritation and by inhibition of prostaglandin E2 biosynthesis in gastric mucosa. There is therefore the potential for serious adverse interaction between them. The use of non selective adrenergic -blocking drugs in patients with insulin requiring diabetes is such a case, since such patients may depend on sensations initiated by activation of receptors to warn them of impending hypoglycemic coma. Also the recovery from insulin induced hypoglycemia depends on adrenalin mediated release of glucose ( by glycogenolysis) form skeletal muscles and liver via adrenergic receptors Alterations in fluid and electrotyte balance constitute an important source of pharmacodynamic drug interaction Thiazide and loop diuretics commonly cause mild hypokalemia, which is usually of no consequence. However, the binding of digoxin to plasma membrane Na+/K+ adenosine triphosphatase (ATPase), and hence its toxicity, is increased when extracellular potassium concentration is low. Concurrent use of such diuretics therefore increases the risk of digoxin toxicity. 2-Agonists such as salbutamol also reduce plasma potassium concentration, especially when used intravenously. Conversely, potassium-sparing diuretics may cause hyperkalemia if combined with potassium supplements and/or converting enzyme inhibitors (which reduce circulating aldosterone), especially in patients with renal impairment. Hyperkalemia is one of the commonest causes of fatal adverse drug reaction.
182 Interactions secondary to drug-induced alterations of fluid and electrolyte balance.
Primary drug Digoxin Lignocaine
Interacting drug effect Diuretic-induced hypokalemia
Result of interaction Digoxin toxicity Antagonism of
Diuretic-induced hypokalemia
antiarrhythmic effects Antagonism of diuretic
Diuretics NSAID-induced salt Tubocurarine Lithium and water retention
effects
Prolonged paralysis Diuretic-induced hypokalemia Thiazide-induced Raised plasma lithium
Angiotensin-converting enzyme inhibitor
reduction in renal clearance Potassium chloride and/or patassiumretaining diureticinduced hyperkalemia
Severe hyperkalemia
183 III Pharmacokinetic interactions In these, one drug affects the absorption, distribution, metabolism and excretion (ADME) of another drug with the resultant change in the plasma concentration of another drug. Absorption Different mechanisms affect the gastrointestinal absorption of the drug. The amount of drug absorbed may be reduced or delayed which decreases the drug plasma concentration level,reducing the therapeutic effect. [i] PH: The PH of the G contents affects the absorption of drugs. The non-ionised form of drug (the more lipid soluble) gets absorbed more readily than the ionised form of drug. The acidic drugs will remain in the non-ionised form in the stomach (low PH), hence these will get readily absorbeds. If antacid is administered with acidic drugs, it will raise the PH of GI contents and inhibits the absorption. The enteric coated bisocodyl (oral dosage form of laxative) should not be given with antacid or milk because increase in PH of GI contents may cause disintergration of enteric coating releasing of enteric coating releasing the drug in stomach causing irritation and vomitting. [ii] Complexation: Drugs like tetracycline form complexes with metal ions such as calcium, magnesium,aluminium and iron which are poorly absorbed. Hence tetracycline should not be administered along with milk (containing calcium) and [iii]Adsorption : Antidiarrhoeal mixtures contain the adsorbents like kaolin which adsorb the other medications.if administered simultaneously, which decreases the absorption of these drugs. [iv] Changes in GI motility: Drug like cathartics increase the GI motility resulting in a decreased absorption of drugs which are normally absorbed slowly and which reuire prolonged contact with absorbing surface. Anticholinergic drugs decreas GI motility, motility, resulting in increased absorption of drug. The effect may be decreased absorption of drug due to slow dissolution of drug. General pharmacology
184
185 Cholestyramine inhibits the GI absorption of acetaminophen. In addition to direct interaction within the gut lumen, drugs that increase or reduce the rate of gastric emptying (e.g. metoclopramide or propatheline, respectively) can alter the rate or completeness of absorption of a second drug, particularly if this has low bioavailability (v) Food: The presence of food in stomach influences the absorption of number of drugs. The food also reduces the absorption of drug by binding with it, or by changing the PH of GI contents it reduces the dissolution rate of drug. The absorption of antibiotics is reduced in presence of food. Hence penicillin and tetracycline derivatives should be given 1 hour before meal or 2 hour or after meal to achieve optimum absorption. Some drugs such as diazepam achieve, higher serum level following food wherease drug likeclimetidine needs slower absorption hence it is advantageous to take it with meal. (vi) Inhibition of GI enzymes: The absorption of certain drugs depends on their metabolism by the enzymes. If these enzymes are inhibited then the absorption of drugs also decreases. For example:Folic acid Phenytoin interaction. Phenytoin inhibits the enzyme intestinal conjugate which is responsible for conversion of poorly absorbed form of folic acid i.e. polyglutamate to readily absorbed form of folic acid i.e.,monoglutamate. This results into deficiency of folic acid. (Anemia). Distribution Plasma and tissue binding site interactions One large group of potential drug interactions that consists of drug that displace one another from binding sites on plasma albumin or within tissues. The displacing drug will increase the effects of the displaced drug by increasing its free (unbound) concentration. E.g unjudicious treatment with drugs such as sulfonamides that displace bilirubilin from the binding sites (albumin) may permit diffusion of free bilirubin across the immature blood-brain barrier and consequent staining of and damage to basal ganglia (kernicterus) and subsequent choreoathetosis in the child. General pharmacology
186
187 Instances where clinically important consequences do occur on introducing a drug that displaces another from tissue binding sites are often in fact due to additional actions of the second drug on elimination of the first. For instance, quinidine displaces digoxin from tissue binding sites and can cause digoxin toxicity, but only because it simultaneously reduces the renal clearance of digoxin by a separate mechanism. Phenylbutazone displaces warfarin from binding sites on albumin and can cause excessive prolongation of the prothrombin time and bleeding. More importantly, drugs can interfere with the enterohepatic recirculation of other drugs e.g. failure of oral contracention (particularly low-dose estrogen preparations) can result from concurrent use of antibiotics as a result of damage to normal microbial flotra and thus retard the enterohepatic recirculation of oral contraceptives( refer plasma protein binding) Metabolism Decreased efficacy can result from ENZYME INDUCTION by a second agent Table 3. Interactions due to enzyme induction. Primary drug Warfarin Inducing agent Barbiturates Alcohol Rifampicin Decreased anticoagulation Effect of interaction
Oral contraceptives Prednisolone/Cyclosporin
Rifampicin Anticonvulsants
Pregnancy Reduced immunosuppression (graft rejection) Decreased plasma theophy-lline
Theophylline
Smoking
188 Historically, barbiturates were clinically the most important enzyme inducers, but with the decline in their use, other anticonvulsants, notably carbamazepine, and the antituberculous drug rifampicin are now the commonest cause of such interactions. These necessitate special care in concurrent therapy with warfarin, phenytoin, oral contraceptives, glucocorticoids or cyclosporin. ENZYME INHIBITION (inhibition of drug metabolism) may also produce toxicity. The time course of such interactions is often shorter than for enzyme induction, since it depends merely upon the attainment of a high enough concentration of the inhibiting drug at the metabolic site. Xanthine oxidase is responsible for inactivation of 6-mercaptopurine, itself a metabolite of azathioprine. Allopurinol markedly potentiates these drugs by inhibiting xanthine oxidase. Xanthine alkaloids (e.g. theophylline) are not inactivated by xanthine oxidase, but rather by a form of cytochrome P450. Theophylline has serious (sometimes fatal) dose-related toxicities, and clinically important interactions occur with inhibitors of the cytochrome P450 system, notably cimetidine, ciprofloxacin and erythromycin. Erythromycin also inhibits cyclosporin A metabolism, and can cause severe toxicity. Inhibition of metabolism: Isoniazid inhibits the hydroxylation of diphenyl hydantoin and may cause toxicity of diphenyl hydatoin. Erythromycin hybits the hepatic metabolism of cabamazepine increasing its toxicity. The enzyme xanthine oxidase (responsible for metabolism of meracaptopurine ) is inhibited by Allopurinol, reducing the production of uric acid. Excretion Many drugs share a common transport mechanism in the proximal tubules, and can mutually reduce one anothers excretion by competition. Aspirin and non-steroidal anti-inflammatory drugs inhibit secretion of methotrexate into urine, as well as displacing it from protein binding sites, and can cause methotrexate toxicity. (IV) Interactions Affecting Excretion: One drug may block the renal excretion of another by competing for the same tubular transport system or may increase the excretion of the drug by increasing it ionisation. General pharmacology
189 Inhibition of excretion: Probenecid competes with penicillin in renal secretion and hthus inhibits the excretion of penecillin clofibrate. Probenecid also decreases the renal excretion of methotrexate and clofibrate. Quinidine and verapamil both cause the increase in the serum digoxin level by inhibiting the renal tubular secretion and renal excretion and nonrenal clearance of digoxin. (ii) Increase in renal excretions: Antacids like sodium bicarbonate make the urine alkaline and
thus enhance the ionization of weak acidic drugs like salicylates, barbiturates and lead to their rapid excretion Changes in urinary pH alter excretion of drugs that are weak acids or bases, and administration of systemic alkalinizing or acidifying agents or carbonic anhydrase inhibitors change the concentrations of these drugs in plasma and urine (e.g. excretion of salicylate and of phenobarbitone is increased in alkaline urine). Such effects are seldom of clinical significance, although they are sometimes of value in the management of overdose to increase drug elimination.
Primary drug Penicillin Methotrexate
Competing drug Probenecid Salicylates Sulfonamides
Effect of interaction Increased penicillin blood level
Bone-marrow suppression
Salicylate Indomethacin Chlorpropamide Digoxin
Probenecid Probenecid Phenylbutazone Spironolactone Amiodarone Verapamil
Salicylate toxicity Indomethacin toxicity Hypoglycemia
Increased plasma digoxin
190
191
Drug-food interactions In most cases, food reduces drug absorption and thus inhibits the effects of drug whose actions are related to concentration maxima (Cmax) in plasma (hypnotics, CNS stimulants). Food is not recommended before their administration. There are some specific types of food-drug interactions: Non-selective monoamine oxidase inhibitors (e.g. phenelzine) potentiate the action of indirectly acting amines such as tyramine, which is present in a wide variety of fermented products (Camembert and other soft cheeses, yeast extract and Chianti wine amongst others),resulting in hypertensive crisis Tetracyclines form insoluble complexies with food containing calcium (milk and diary products). In this way, absorption of tetracyclines may be markedly reduced. Protein rich food .interfere with the absorption of levo DOPA due to the rich supply of aminoacids compete with levo DOPA for the carrier protein aromatic amino acid carrier protein in GIT Food may prolong the rate of stomach emptying and thus increase the amount of an effective compound slowly released from the formulation. Administration of such a drug is recommended after the meal (griseofulvin)
192 C ap X h ter IV E volu ation of N D gs ew ru DRUG DISCOVERY new drugs are discovered and identified through one of the following approaches Random Screening It is a sort of blind hitting procedure where a new entity (naturel/ synthetic) are
subjected to pharmacological screening procedure to explore different types of biological activities using various animal models or isolated tissue preparations.many of them are found in this way from its folklore uses. E.g morphine, atropine & quinidin Serendipity (happy observance or by chance) a new use is discovered from an old drug or its side effect found a new therapeutic use. e.g. penicillin G and the anti arrhythmic use of the local anesthetic lidocaine. Molecular Modification of the Known Drug the chemical analogue of thr established drugs are
synthesized and tested for their biological activitity to yield a new compound. e.g the synthesis of semi synthetic derivatives of penicillins and cephalosporins. Rational Drug Designing this type of discovery is based on the relation ship between the biological
activity and the chemical structure ies by utilizing the knowledge on SAR( structural activity relation ship) e.g development of ACE inhibitors and H2 antagonists Designing of a Prodrug or an Active Metabolite Prodrug is an agent that is administered as the precursor
of a drug and is converted into active therapeutic agent inside the body. e.g Levodopa a prodrug of neurotransmitter dopamine, in the treatment of parkinsonism. Besides prodrugs, active metabolites of certain drugs are also found toposses ttherapeutic advantage over parent drug For example; paracetamol metabolite of phenacetin was introduced sa asafe analgesic this way. After the synthesis or isolation of the test drug its purity is ascertained by physico-chemical and analytical studies.A promising compound (LEAD COMPOUND) selected this way is then General pharmacology
193 subjected to pre-clinical evaluation followed by clinical evaluation provided the pre clinical evaluations are promising and encouraging. -PRECLINICAL EVALUATION (ANIMAL STUDIES) Aim: to define the pharmacological profile of the lead molecule. Screening may be either organ oriented or disease oriented. All done using various experimental models to gain the desired objective. a) b) c) d) e) Its involve four main areas Pharmacodynamic Studies Toxicological studies Pharmacokinetic studies Assessment of safety index Pharmacodynamic Studies Here actions relevant to the proposed therapeutic use (and other effects) are studied on animals. For example, in search for an antihypertensive activity of the lead compound, study can be undertaken on dogs, cats or rats to find out systolic-diastolic blood pressure changes and other cardiac effects like ECG changes, pathological changes biochemical, ionotropic-chronotropic effects, cardiac output and total peripheral resistance. Once the lead an exhibits promising resultsthe stud ies can be further made at cellular level. An evidence for it receptor activity can also be gathered in-vitro on cultured cells. Depending on the results, the studies can be further extended to molecular level to find out receptor affinity and selectivity by performing in vitro receptor binding studies on cell membrane fractions from organs or cultured cells. The graded response assays or quantal assays are then performed to find out ED 50 of the drug. Toxicological Studies If the agent possessed useful activity, it should now be studied for possible adverse effects on other major organ systems.and they are: Acute Toxicitystudies Aim: to find out the acute dose lethal to 50% of the animals(LD50). Conducted on atleast two animal species. The drug is given in graded fashion to several groups of
194 animals by atleast by two routes. One of which should be the proposed route to be used in human beings. All being done as per OECD guidelines.
195 Sub acute toxicity studies Aim: To identify the target organs suseptable to drug toxicity. Three doses are used on two animal species. The animals are maintained at maximum tolerated doses for a minimum period of 4 week to a maximum of 3 months. There after biochemical and haematological changes are evaluated and finally the animals are sacrificed and subjected to histopathological studies. Sub chronic toxicities studies: are done for 13 weeks to 4 months. Chronic toxicity studies: Aim: To identify the target organs suseptable to drug toxicity if the drug is intented for chronic use in human beings. Done on two animal species (rodent and non rodent). Duration of study may range from 1-2 year. There after biochemical and haematological changes are evaluated and finally the animals are sacrificed and subjected to histopathological studies. Special Toxicity studies: Nowadays, toxicological data on teratogenicity (including the effects on reproductive functions) mutagenicity and carcinogenicity have become mandatory after the unfortunate episode of thalidomide disaster in 1950 which left more than 10,000 newborns congenitally deformed and crippled due to phocomelia. Effect on reproductive performance. Studies are carried out on rats treated with the test drug before and after mating period. Effects of drugs on mating behavior, fertility, parturition and lactation are noticed including pernatal and postnatal effects if any. Teratogenicity. Aim to study the effect of drugs on organogenesis. Doses are used on in two animal species af ter the mating, during the period of organogenesis. Foetus is then examined for any skeletal visceral abnormality. Carcinogenicity. Aim tio check the carcinogenic potential of the drug. Two animal species are used and the dose selected is same asthat of chronic toxicity study. The duration of the study is for 2 years with the assessment of haematological and histopathological studies. Mutagenicity. Drugs may cause abnormalities of genetic material (genes and chromosomes) of cells so that a permanent change in the hereditary constitution occurs (mutation). When a General pharmacology
196 mutation occurs in reproductive cells (spermatozoa or ova) then a hereditary defect occurs which may appear in the first generation progeny of individuals. However, if it is a recessive kind of trait, it may become evident when two individuals affected by chemical mutagen mate. This type of the toxicity is studied ion genetic stability of the bacteria (AMES TEST). Mutagenicity can also be studied on mammalian cell coltures. When a mutation occurs in somatic cells then these tissues may become malignant. Pharmacokinetic studies. After the successful complation of toxicological studies the promising lead compound is subjected to pharmacokinetic studies in several species of animals like rats, dogs, and some times on monkeys. And studies are done on absorption, distribution, metabolism, excretion, bioavailabilty after oral administration and its elimination half life. Assessment of Safety Index From the toxicological and pharmacodynamic data, the LD50 and ED 50 of the test compound), are found, respectively. From these data, its therapeutic index and certain safety factor is also calculated. CLINICAL TRIALS (HUMAN STUDIES) When the new compound passes the pre-cliniincal pharmacological screening the manufacturer may file a "preclinical new drug" or"Investigational New Drug" application to an authorized drug control body of the respective country. The IND application must contain the following information about the test drug. The chemical structure, its source, its manufacturing data with details of its purity. The pre-clinical data about pharmacodynamics, pharmacokinetics and toxicological studies with ED 50 and Specification of dosage forms in which it has to be administered to human beings. A detailed description of the investigational protocol to be undertaken (including the dose and route of The names and qualifications of each investigator and the facilities available to them. An agreement from the sponsors to submit annual progress report. A certification that "informed consent" will be obtained from human volunteers and that "ethics of research beings" will strictly be followed. The sponsors have to also ensure that copies of all informational
LD50 data.
administration).
in human
material have been supplied to each investigator.
197 Only when the approval is given by this body, the drug can be administered to the men for clinical trials.
198 Ethics of Research in Man The healthy human volunteers or patient volunteers should have the right to choose for themselves whether or not they will participate in research The law requires that the physician should obtain the writteninforme4d concent fron every human volunteer. It should invlve the following basic elements. 1. 2. 3. 4. 5. 6. A fair explanation of the procedures to be followed An explanation of the possible discomforts and risks A description of the anticipated benefits (particularly when the volunteers are like cancer patients) A permanent offer to answer any query related to the procedure; An assurance that the subject free to withdraw his consent and to discontinue participation in the project at An explanation of compensation or available medical treatment if adverse effects appear. Thus, although a large number of subjects participate in clinical trials, almost every subject is fully informed of the actions of the drug, the purpose of study and the benefits to be derived out of it. 7. Women with child bearing potential are never subjected to clinical trials unless the rigorous teratologic
any time
studies in aniwals have been completed. Also, with an obvious exception of the clinical trials with new contraceptive drugs, no women should be used as subjects if they are willing to bear the child either during or immediately after the end of clinical trials. 8. 9. A new drug is frequently compared with `placebo', but the use of 'placebo controls' is necessary and Placebos have a right- ful place in the studies to be carried out on healthy volunteers in whom the new drug appropriate only under cer-tain circumstances is of no direct therapeutic benefit to the sub ject (for example: when a new drug is claimed to be an appetite stimulant or sup-pressant, i.e. when the subjective effects of the drug are under study). These are equally appropriate in the clinical trial of an abso lutely new drug for which there are no existing counterpart ( clinical efficacy of an entirely new vaccine).
199 Phases of Clinical Trials it consisit of four phases Phase I It is the phase of clinical pharmacological evaluation of a new drug. Performed in small number of healthy volunteers (20-25) If the drug is expected to have significant toxicity the volunteers with particular disease are used e.g. anticancer drugs. Objectives of Phase I 1. 2. 3. To determine whether humans and animals show significant pharmacokinetic differences. To determine a safe and tolerated dose in humans. The selection of an initial dose is difficult because the The common rule is to begin with 1/5th or 1/ 10th of the maximum tolerated dose (mg/kg) in animals and
toxicological data on animal are of limited usefulness (quantitatively) for selecting such a dose. calculating it for an average human body weight of 70 kg. The drug is then given in small increments till the therapeutically effective dose is attained by clinical observation 4. To determine any predictable toxicity. These trails are NON-BLIND or OPEN that means both the investigator and the subjects know what is being given. Phase I studies are usually performed by clinical pharmacologists in a research centre especially equipped pharmacokinetic studies. Phase II In this phase the study is done for the first time in patients with target disease to determine the efficacy of the drug. This phase is divided in to two ies EARLY and LATE PHASES. In the EARLY PHASE, a small number of patients (20-200) are involved. Objectives 1. To observe potential therapeutic benefits and sideeffects.
200 2.
To establish a dose range for more definitive therapeutic trials to be undertaken in the late phase It is usually a SINGLE BLIND design where only the subject does not know whether he is taking an inert placebo or a positive control drug or the new drug. The LATE PHASE are conducted on a larger number of patients (50-300) Objectives
1. 2.
to ensure safety and efficacy of the new drug in a specific disease to compare these data with that of the standard drug (in market) used for the same disease. It is conducted in DOUBLE BLIND manner, where the invest tigator and the subject is ignorant whether a placebo, or a positive control medicine or the new drug under trial is used. This is done to rule out the influence of preconvinced notion or benign communication by the investigator to his subjects and a third party holds the code identifying medication and this code is not deciphered until the clinical data have been collected. PHASE III These are large scale randomized control trials in patients (250-1000 plus) to further establish the safety and efficacy of the drug under study. Objectives These are designed to minimise errors in the information gathered in Phase I and II trials DOUBLE BLIND CROSS OVER designs where the invest tigator and the subject is ignorant whether a placebo, or a positive control medicine or the new drug under trial is used and they are administered in alternative periods and the sequence is systematically altered as per Latin square rule.
201
Patient groups(random ized) I standard drug II placebo new drug standard drug III new drug standard drug It si conduceted by a large number of clinitians at different centers. Duration may average to five years. At the end of trails the statistical analysis of the data is perfomed to determine the significance of the results. New Drug Application ON COMPLETION OF Phase III trails the sponsor can file a "New Drug Application" with the drug control authorities of that country. The new drug application usually contains complete detailed monograph of the product, the results of the trials, the proposed registered name of this product and the package insert. The data are reviewed by the drug control authorities and even by outside consultants who may require further information or clarification. If the documentation is acceptable and is in compliance with the regulations, the drug control authorities can allow the drug to enter the market with "New Drug Status". PHASE IV Once approval is obtained to market the drug, phase IV of the trials begin.. It is the post-licensing phase (field trials). The phase IV has no fixed duration as it is the surveillance phase during the post marketing clinical use of the drug. The performance of the drug is monitored for several years, immediately after marketing, to discover relatively rare side effects or previously General pharmacology placebo Medication given
placebo
new drug
202 unknown therapeutic uses detected by a chance discovery. during the "New Drug Status" period, the manufacturer is expected to report any new information about the drug concerning its safety. The drug may remain in "New Drug Status" (i.e. in controlled marketing) for several years until the drug control authorities are confident for its re lease to unrestricted marketing. PHARMACOGENETICS (Pharmacogenetic variations in drug actions) Pharmacogenetics is concerned with drug responses that are governed by heredity. Heredity or genetic factors play important role in modifying drug action. Individual variation of dose, drug biotransformation, drug effect including adverse drug effect are mostly genetically determined. Genetic diffecrences also exist among different races. For example Chinese, Mongoloids, Blacks, Whites all are not equal in terms of pharmacological effect of many drugs. Pharmacogenetics deals with all these individual variations due to genetic causes.Most of the drugs undergo animal studies specially for acute , subacute and chronic toxicity,& for determining therapeutic index, pharmacokinetics etc. But genetically animals cannot be identical to human beings. Pharmacogenetics also deals with this problem. Examples: Heritable conditions causing increased or toxic drug responses: Acetylator status: INH may cause peripheral nephropathy in slow acetylator group. It may cause liver damage in rapid acetylator group. G-6PD deficiency Group: Haemolysis occur if exposed to certain drugs such as Primaquine, Sulphonomides. Heritable conditions causing decreased drug response: Resistance to Suxamethonium if Pseudocholinesterase activity is congenitally more. Some individuals are resistant to vitamin D. Importance: Familiarity with Pharmacogenetic conditions can help physicians to administer drugs more safely. General pharmacology
203 Pharmacogenetic prescreens (Molecular diagnostic tests for Pharmacogenetic variants) could markedly decrease the risk of individual patients e.g Measurement of GL 6-PD level in RBC helps in avoiding adverse effects of many drugs. Important consequence of Pharmacogenetic variation is Idiosyncratic reactions.
204
Chapter XV ESSENTIAL DRUG CONCEPT Definition: Essential drugs imply that, In a given situation the drugs which are called essential are the most needed drugs, to satisfy the health needs of vast majority of the population and that they should be made available in proper dosage forms, at all the times in adequate amounts, in acceptable quality and at a price that people can afford. WHO originally conceived the concept of essential drugs in 1975. The essential drug list published by WHO serves as model list for the member states for preparing national essential drug list. Now more than 80 countries in the world have their own essential drug list. The difficulty of putting this into practice is reflected in the rather longer and more categorical 2002 definition: 'Essential medicines are those that satisfy the priority health care needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness. Essential medicines are intended to be available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality and adequate information, and at a price the individual and the community can afford. The implementation of the concept of essential medicines is intended to be flexible and adaptable to many different situations; exactly which medicines are regarded as essential remains a national responsibility. Objectives: Major objectives of WHO action program of essential drugs is: 1. 2. 3. 4. To develop and improve drug supply system To assist in developing National Drug Policy To ensure the availability of safe and effective drugs of acceptable quality and at the lowest possible cost in To promote rational use of drugs in the globe
support of primary health care for the people where ever they may be.
205 Selection criteria: Essential medicines are selected with due regard to disease prevalence, evidence on efficacy and safety, and comparative cost-effectiveness Purpose: Essential medicines are intended to be available within the context of functioning health systems at all times, in adequate amounts, in the appropriate dosage forms, with assured quality, and at a price the individual and the community can afford. Implementation: The implementation of the concept of essential medicines is intended to be flexible and adaptable to many different situations; exactly which medicines are regarded as essential remains a national responsibility. NATIONAL LIST OF ESSENTIAL MEDICINES 2003 an example Medicine Category Route of Administration/ Strengths Disease Modifying Agents used in Rheumatoid Disorders Medicine Azathioprine Chloroquine Phosphate Methotrexate S, Sulfasalazine Anthelminthics Intestinal Anthelminthics Albendazole U Tablets Suspension Mebendazole U Tablets 400 mg 200 mg/ 5 ml 100 mg General pharmacology S, T Tablets T Tablets 2.5 mg 500 mg Category S, S, Route of Administration/ Dosage Form T Tablets T Tablets Strengths 50 mg 150 mg
206 Suspension Niclosamide Pyrantel Pamoate U U Chewable Tablets Tablets Suspension 100 mg / 5 ml 500 mg 250 mg 250 mg / 5 ml
207
P - DRUGS The drugs you are going to prescribe regularly and with which you will be familiar are called P (personal) drugs. The P- drugs concept includes: 1. 2. 3. 4. The name of a drug. Dosage form Dosage schedule Duration of treatment for a specified condition Due to varying availability and cost of drugs, different national formularies, and essential drug list, medical culture and individual interpretation of information P drugs differ from country and between doctors. Following reasons that indicate why a P- drug should never be the one that has been suggested or indicated by clinical teachers, senior colleagues, or sales representatives. The latest and most expensive drug is not necessarily the best, the safest, and the most cost effective By developing ones own set of P drugs one can learn to handle pharmacological concepts and drug related data in an effective manner Can prescribe alternatives One has the final responsibility for his/her patients wellbeingwhich he/she cannot pass on to others.
208 Steps in selection of p-drugs: Defining the diagnosis: The patient problems are defined and a diagnosis is made Specifying therapeutic objective(s): What we want to achieve with the treatment. Is it for cure or prevention? Making an inventory of effective groups of drugs: To make a list of at least 2-4 appropriate group of drug Choosing an effective group according to criteria: Out of 2-4 groups , one most appropriate group to be Efficacy: is compared on the basis of pharmacodynamic considerations Safety: is compared on the basis of side effect profile Suitability: applies to kinetic considerations matched with patients factor such as age, pregnancy, liver and Choosing a P-drug: A specific drug within the group to be chosen. Same criteria of efficacy, safety,
chosen comparing, efficacy, safety, suitability, and cost.
kidney function etc. suitability, and cost can again be used. Example: Patient I : A 60 yr old man with no previous medical history , has had several attacks of suffocating chest pain during the last month , which began during physical labor and disappeared with rest .He has not smoked for 4 years. His father and a brother died of a heart attack. Excepting occasional aspirin, he has not used any medication. Physical examination reveals no abnormality blood pressure is 130/80, pulse 78 regular and body weight is normal. Clinical diagnosis is angina pectoris. Selection of a P-drug for angina pectoris Define the diagnosis-Stable angina pectoris Specify therapeutic aim-Prevention of anginal symptoms, reduce myocardial oxygen need by decreasing preload, heart rate or after load. Make inventory of effective groups Nitrates, blockers, Calcium channel blockers, Potassium channel openers
209
Choose a group according to criteria Drug Groups Efficacy Safety Suitability Cost
Nitrates (tablet) blockers (tablet) Calcium channel blockers(tablet)

Potassium channel openers(tablet)
+ + + +
++ +
+ + -
Choose a P drug Individual drugs Efficacy Safety Suitability Cost
Nitrates (tablet) blockers (tablet) Calcium channel blockers(tablet)

Potassium channel openers(tablet)
+ + + +
++ +
+ + + -
Write a prescription Active substance, dosage form Dosage schedule Duration Atenolol, 50 gm tablet 50 gm once daily Length of monitoring interval
210 RATIONAL USE OF DRUG (RUD) Drugs are used in medical practice to save a life. Drugs can save a life when used appropriately that is rationally. On the other hand, they can be disastrous to a life when they are used inappropriately. So before prescribing or using drug first point which should be considered is RATIONAL USE OF DRUG. Rational use of drug is still an unsolved problem throughout the world. The medical profession is not entirely guiltless in their use of drugs. In both the developed and the developing world medically inappropriate, ineffective and economically inefficient use of pharmaceuticals is commonly observed in health care facilities. There has been a good deal of excessive, and occasionally ignorant and irresponsible prescribing for which there are many reasons. The cost of such irrational drug use are enormous in terms of both scarce resources and the adverse clinical consequences of therapies, which may have real risks but no objective benefits. Rational use of drug demands not only the appropriate drug is prescribed but that it should be available when needed and at a price that people can afford. The concept of 'Rational use of drugs' is based on rules of right. That is it can be taken in a 1. 2. 3. 4. 5. right medical condition, in right doses, at right intervals for the right length of times It should be effective and be of acceptable quality, and safe. Criteria for rational use of drugs Appropriate indication: The decision to prescribe is entirely based on medical rationale and that drug therapy is an effective and safe treatment. General pharmacology
211 Appropriate drug: The selection of drugs is based on efficacy, safety, suitability and cost consideration. Appropriate route of administration: Right route of drug administration must be selected Appropriate patient: No contraindication exists and the likely hood of adverse reactions is minimal. Appropriate information: Patient should be provided with, RELEVANT, ACCURATE, IMPORTANT AND CLEAR information regarding his or her condition and the MEDICATIONS that are prescribed along with clear instruction how to use these medications. Appropriate monitoring: The anticipated and unexpected effects of medications should be appropriately monitored through drug information system. IRRATIONAL USE OF DRUGS Irrational use of drug may be due to inappropriate prescription or due to inappropriate selfmedication. Other factors such as drug supply system, drug regulation, and drug promotion may influence irrational use of drug in the community. Commonly encountered inappropriate use of drugs is: 1. 2. 3. 4. 5. Overuse and misuse of antibiotics including use of newer generation costlier drugs when Use of anabolic steroids for improving physical health Use of antidiarrhoeal agents such as Lomotil(Loperamide) for nonspecific diarrhoeal diseases Missuse of sedatives, antihistamines and cough mixtures Missuse of potent NSAIDs. Causes of irrational use of drugs: Patient/ consumer factor: Patient's demand for a particular brand of medicine, Lack of education and information regarding the hazards of inappropriate/ unnecessary medication, and risk/ benefit of unnecessary use of drugs, .Self-medication, Misleading beliefs
effective, cheaper alternative drugs are available in the market.
212 Prescriber factor Inadequate education and training of health care personnel regarding the appropriate use of drugs Lack of objective drug information (National formularies, Standard treatment guideline etc) Heavy patient load Tendency of the prescribers to prescribe the latest and expensive brand of a particular drug available in the market, which they think, would be superior to the old or less expensive existing one. Misleading belief about drugs efficacy. Drug regulation factor Insufficient regulatory mechanism, such as certain drugs like antibiotics and steroids are sold without prescription Drug promotion factor Misleading claims, biased drug promotional materials etc. Impact of irrational use of drugs Wastage of resources Increased morbidity Increased mortality
213 PHARMACOGENETICS A person's environment, diet, and general state of health can all influence how he or she responds to medicines. But another key factor is genes. The study of how people respond differently to medicines due to their genetic inheritance is called pharmacogenetics.Pharmacogenetics is generally regarded as the study or clinical testing of genetic variation that gives rise to differing response to drugs. In the future, advances gleaned from pharmacogenetics research will provide information to guide doctors in getting just enough of the right medicine to a person-the practice of "personalized medicine." PHARMACOGENETICS Genetic variability is seen both in the area of pharmacokinetics (absorption, distribution, metabolism and excretion, ADME) and in the area of pharmacodynamics (drug effects). For example genetic variations can influence the activity or have an effect on the expression of the following proteins: Drug metabolizing enzymes, DMEs (Phase I enzymes/Cytochrome P450 Drug transporters (Solute Carrier (SLC)- and ATP Binding Cassette (ABC)Drug receptors (ligand controlled ion channels or class 1 receptors, e.g.
enzymes, e.g. CYP2D6; Phase II enzymes, e.g. N-acetyl transferases) transporters, e.g. organic cation transporters, OCTs, as members of the SLC family) glutamate receptor; G-protein coupled receptors (GPCRs) or class 2 receptors, e.g. -receptor; enzymatic receptors, e.g. insulin receptor; receptors regulating gene expression, e.g. steroid hormone receptor e.g. GNAS1 or GNB3
214 Cytochrome P-450 enzymes are the key enzymes of phase I metabolism for detoxification of foreign substances. These are primarily liver enzymes which are involved in conversion and degradation of a large number of drugs. Variants in genes coding for these enzymes lead to different types of metabolizers. fast metabolizers show no effect of certain drugs because at normal dosages drugs are degraded too fast.Poor metabolizers/slow metabolizershowever, it comes to an accumulation up to ten-fold referring to the desirable standard value with the risk of severe side effects. POLYMORPHISM The most important aspect is the genetic variability between individuals in their ability to metabolize drugs due to expression of 'polymorphic' enzymes. Polymorphism enables division of individuals within a given population into at least two groups, poor metabolisers (PMs) and extensive metabolisers (EMs) of certain drugs. The two most extensively studied genetic polymorphisms are those involving cytochrome P450 2D6 (CYP2D6) and CYP2C19.CYP2D6 metabolizes a number of antidepressants,antipsychotics, beta-adrenoceptor blockers, and antiarrhythmic drugs. CYP2C19 enzyme participates in the metabolism of omeprazole, propranolol and psychotropic drugs such as hexobarbital, diazepam, citalopram, imipramine, clomipramine and amitriptyline GENETIC VARIATIONS REVEALED SOLELY BYTHE EFFECTS OF DRUGS Among the best-known examples of drugs that have been responsible for revealing genetic variation in response are isoniazid, primaquine, certain anesthetic agents and alcohol.
215 N-ACETYLTRANSFERASE ACTIVITY Isoniazid is one of the drugs used in the treatment of tuberculosis. The metabolism of isoniazid allows two groups to be distinguished: rapid and slow inactivators. In the former, blood levels of the drug fall rapidly after an oral dose; in the latter, blood levels remain high for some time. Family studies have shown that slow inactivators of isoniazid are homozygous for autosomal recessive allele of the liver enzyme N-acetyltransferase (NAT), with lower activity levels NAT activity varies in different populations. In the USA and W Europe about 50% of the populations are slow inactivators, in contrast to Japanese, who are predominantly rapid inactivators.Blood levels of isoniazid remain higher for longer periods in slow inactivators than in rapid inactivators on equivalent doses.Slow inactivators have a significantly greater risk of developing side-effects like pheripheral neuritis.Conversely, rapid inactivators have an increased risk of liver damage due to Isoniazid N acetylated metabolite which is hepatotoxic. DNA studies of NAT Studies in other animal species led to the cloning of the genes responsible for NAT activity in humans. This revealed that there are three genes, one of which is not expressed and represents a pseudogene (NATP), one that does not exhibit differences in activity between individuals (NAT1), and third (NAT2), mutations in which are responsible for the inherited polymorphic variation. These inherited variations in NAT2 have been reported to modify risk of developing a number of cancers that include bladder, colorectal, breast and lung cancer. This is thought to be through differences in acetylation of aromatic and heterocyclic amine carcinogens.
216 GLUCOSE-6-PHOSPHATE DEHYDROGENASE VARIANTS For many years, quinine was the drug of choice in the treatment of malaria. In 1926 primaquine was introduced and proved to be much better than quinine in preventing relapses but some people were found to be sensitive to the drug. After a few days of drug taking suddenly some individuals would begin to pass very dark, often black, urine. Jaundice developed and the red blood count and hemoglobin concentration gradually fell as consequence of hemolysis of the red blood cells. The cause of such cases of primaquine sensitivity is a deficiency in the red cells enzyme glucoso-6-phosphate dehydrogenase (G6PD), an important antioxidant. Family studies have shown that G6PD deficiency is inherited as an X-linked recessive trait. Persons with G6PD deficiency are sensitive to many other compounds.The main risk of G6PD is favism, in which a hemolytic crisis occurs after eating fava beans. MALIGNANT HYPERTERMIA Malignant hyperthermia (MH) is a rare complication of anesthesia (halothane is used). Susceptible persons develop muscle rigidity as well as an increased temperature often as high as 42.3 C during anesthesia.If it is not recognized rapidly and treated with vigorous cooling, the affected individual will die.MH susceptibility is inherited as an autosomal dominant trait affecting approximately 1 in 10 000 persons. Prediction requires a muscle biopsy with in-vitro muscle contracture testing in response to exposure to halothane and caffeine. MH is genetically heterogeneous bust most common cause is a mutation in the ryanodine receptor (RYR1) gene.Seven other candidate genes have been identified and variants in these genes may influence susceptibility within individual families. This observation may explain the discordant results of the in vitro contracture test and genotype in members of some families that segregate RYR1 mutations
217 ALCOHOL METABOLISM Alcohol is metabolized in the liver by alcohol dehydrogenase (ADH) to acetaldehyde, and further degraded by acetaldehyde dehydrogenase (ALDH). Human ADH consist of dimers of various combinations of subunits of three different polypeptide units coded by three loci, ADH1 coding for the subunit, ADH2 for subunit and ADH3 for subunit.ADH1 is primarily expressed in early fetal life, while ADH2 is expressed in adult life. Persons of Far East Asian origin tolerate alcohol less well than persons of Caucasian origin (whites) and often exhibit an acute flushing reaction to it. This sensitivity is due to differences in the rate of metabolism of acetaldehyde. There are two major ALDH variants or isozymes. ALDH1 which is present in the cytosol and ALDH2 presented in mitochondria. The acute flushing reaction to alcohol has been shown, in fact to be due to absent ALDH2 activity.This unpleasant reaction could account for the reported lower incidence of alcoholism and alcohol related disease in the population EVOLUTIONARY ORIGIN OF VARIATION IN DRUG RESPONSE With most hereditary variation in response to drugs we have very little idea of how and why it arose.A mutation could have conferred selective advantage under certain past dietary or environmental conditions, or have conferred resistance to particular infections. Clinical value of pharmacogenetics The clinical value of understanding pharmacogenetics is in its use to optimize therapeutic efficacy, to prevent toxicity of those drugs whose metabolism is catalysed by polymorphic isoenzymes, and to contribute to the rational design of new drugs.
218 PHARMACOGENOMICS PHARMACOGENOMICS is defined as the study of the interaction of an individual's genetic makeup and response to a drug. The key distinction between pharmacogenetics and pharmacogenomics is that the former describes the study of variability in drug responses attributed to individual genes and the latter describes as a study of the entire genome related to drug response. The expectation is that inherited variation at the DNA level results in functional variation in the gene products which will play an essential role in determining the variability in responses, both therapeutic and adverse, to a drug. If polymorphic DNA sequence variation occurs in the coding region or regulatory regions of genes, it is likely to result in variation in the gene product through alteration of function, activity or level of expression Automated analysis of genome-wide SNPs (single-nucleotide polymorphism) allows the possibility of identifying genes involved in drug metabolism, transport and receptors, which are likely to play a role in determining the variability in efficacy, side-effects and toxicity of a drug. ECOGENETICS An extension of pharmacogenetics is the study of genetically determined differences in susceptibility to the action of physical, chemical and infectious agents in the environment. This has been referred to as ecogenetics. Such differences in susceptibility can be either unifactorial or multifactorial in causation. An extension of pharmacogenetics is the study of genetically determined differences in susceptibility to the action of physical, chemical and infectious agents in the environment. This has been referred to as ecogenetics. Such differences in susceptibility can be either unifactorial or multifactorial in causation. Ecogenetics: genetic variation in susceptibility to environmental agents General pharmacology
219 Environmental agent UV light Foods Fava beans Genetic susceptibility Fair complexion Fats G6PD deficiency Gluten Milk Alcohol Inhalants,Dust Gluten sensitivity Lactase deficiency Atypical ADH -antitrypsin deficiency Celiac disease Lactose intolerance Alcoholism Emphysema Hypercholesterolemia,Atherosclerosis Favism Disease Skin cancer
220 Spurious drugs. --,AS PER DRUGS AND COSMETICS ACT 1940 a drug shall be deemed to be spurious (a) if it is imported under a name which belongs to another drug; or (b) if it is an imitation of, or a substitute for, another drug or resembles another drug in a manner likely to deceive or bears upon it or upon its label or container the name of another drug unless it is plainly and conspicuously marked so as to reveal its true character and its lack of identity with such other drug; or (c) if the label or the container bears the name of an individual or company purporting to be the manufacturer of the drug, which individual or company is fictitious or does not exist; or (d) if it has been substituted wholly or in part by another drug or substance; or (e) if it purports to be the product of a manufacturer of whom it is not truly a product . For the purposes an Ayurvedic, Siddha or Unani drug shall be deemed to be spurious-(a) if it is sold, or offered or exhibited for sale, under a name which belongs to another drug; or (b) if it is an imitation of, or is a substitute for, another drug or resembles another drug in a manner likely to deceive, or bears upon it or upon its label or container the name of another drug, unless it is plainly and conspicuously marked so as to reveal its true character and its lack of identity with such other drug; or (c) if the label or container bears the name of an individual or company purporting to be the manufacturer of the drug, which individual or company is fictitious or does not exist; or General pharmacology
221 (d) if it has been substituted wholly or in part by any other drug or substance; or (e) if it purports to be the product of a manufacturer of whom it is not truly a product.
222 TOLERANCE, HABITUATION, ADDICTION, TREATMENT. Drug dependence means that a person needs a drug to function normally. Abruptly stopping the drug leads to withdrawal symptoms. Drug addiction is the compulsive use of a substance, despite its negative or dangerous effects. A person may have a physical dependence on a substance without having an addiction. For example, certain blood pressure medications do not cause addiction but they can cause physical dependence. Other drugs, such as cocaine, cause addiction without leading to physical dependence. Tolerance to a drug is characterised by the need to increase the dose of a drug in order to produce the phacological response of equal magnitude as that of the initial doses. (needing a higher dose to attain the same effect) is usually part of addiction. Drug abuse can lead to drug dependence or addiction. People who use drugs for pain relief may become dependent, although this is rare in those who don't have a history of addiction. The exact cause of drug abuse and dependence is not known. However, a person's genes, the action of the drug, peer pressure, emotional distress, anxiety, depression, and environmental stress all can be factors. Peer pressure can lead to drug use or abuse, but at least half of those who become addicted have depression, attention deficit disorder, post-traumatic stress disorder, or another mental health problem.Children who grow up in an environment of illicit drug use may first see their parents using drugs. This may put them at a higher risk for developing an addiction later in life for both environmental and genetic reasons.
223 People who are more likely to abuse or become dependent on drugs include those who: 1. 2. 3. 4. 5. Have depression, bipolar disorder, anxiety disorders, and schizophrenia Have easy access to drugs Have low self-esteem, or problems with relationships Live a stressful lifestyle, economic or emotional Live in a culture where there is a high social acceptance of drug use Commonly abused substances include: Opiates and narcotics are powerful painkillers that cause drowsiness (sedation) and sometimes feelings of euphoria. These include heroin, opium, codeine, meperidine (Demerol), hydromorphone (Dilaudid), and oxycodone (Oxycontin). Central nervous system (CNS) stimulants include amphetamines, cocaine, dextroamphetamine, methamphetamine, and methylphenidate (Ritalin). These drugs have a stimulating effect, and people can start needing higher amounts of these drugs to feel the same effect (tolerance). Central nervous system depressants include alcohol, barbiturates (amobarbital, pentobarbital, secobarbital), benzodiazepines (Valium, Ativan, Xanax), chloral hydrate, and paraldehyde. These substances produce a sedative and anxiety-reducing effect, which can lead to dependence. Hallucinogens include LSD, mescaline, psilocybin ("mushrooms"), and phencyclidine (PCP or "angel dust"). They can cause people to see things that aren't there (hallucinations) and can lead to psychological dependence. Tetrahydrocannabinol (THC) is the active ingredient found in marijuana (cannabis) and hashish. There are several stages of drug use that may lead to dependence. Young people seem to move more quickly through the stages than do adults.
224 Experimental use -- typically involves peers, done for recreational use; the user may enjoy defying parents or other authority figures. Regular use -- the user misses more and more school or work; worries about losing drug source; uses drugs to "fix" negative feelings; begins to stay away from friends and family; may change friends to those who are regular users; shows increased tolerance and ability to "handle" the drug. Daily preoccupation -- the user loses any motivation; does not care about school and work; has obvious behavior changes; thinking about drug use is more important than all other interests, including relationships; the user becomes secretive; may begin dealing drugs to help support habit; use of other, harder drugs may increase; legal problems may increase. Dependence -- cannot face daily life without drugs; denies problem; physical condition gets worse; loss of "control" over use; may become suicidal; financial and legal problems get worse; may have broken ties with family members or friends. Symptoms Some of the symptoms and behaviors of drug dependence include: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Confusion Continuing to use drugs even when health, work, or family are being harmed Episodes of violence Hostility when confronted about drug dependence Lack of control over drug abuse - being unable to stop or reduce alcohol intake Making excuses touse drugs Missing work or school, or a decrease in performance Need for daily or regular drug use to function Neglecting to eat Not caring for physical appearance No longer taking part in activities because of drug abuse Secretive behavior to hide drug use General pharmacology
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TREATMENT Treatment for drug abuse or dependence begins with recognizing the problem. Though "denial" used to be considered a symptom of addiction, recent research has shown that people who are addicted have far less denial if they are treated with empathy and respect, rather than told what to do or "confronted." Treatment of drug dependency involves stopping drug use either gradually or abruptly (detoxification), support, and staying drug free (abstinence). People with acute intoxication or drug overdose may need emergency treatment. Sometimes, the person loses consciousness and might need to be on a breathing machine (mechanical respirator) temporarily. The treatment depends on the drug being used. Detoxification is the withdrawal of an abused substance in a controlled environment. Sometimes a drug with a similar action is taken instead, to reduce the side effects and risks of withdrawal. Detoxification can be done on an inpatient or outpatient basis. As with any other area of medicine, the least intensive treatment should be the starting point. Residential treatment programs monitor and address possible withdrawal symptoms and behaviors. These programs use behavior modification techniques, which are designed to get users to recognize their behaviors. Treatment programs include counseling, both for the person (and perhaps family), and in group settings. Drug abuse treatment programs have a long after-care part (when the user is released from the medical facility), and provide peer support. Drug addiction is a serious and complicated health condition that requires both physical and psycholocial treatment and support. It is important to be evaluated by a trained professional to determine the best care. If the person also has depression or another mood disorder, it should be treated. Very often, people start abusing drugs in their effort to self-treat mental illness. General pharmacology
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For narcotic dependence, some people are treated with methadone or similar drugs to prevent withdrawal and abuse. The goal is to enable the person to live as normal a life as possible. Support Groups Many support groups are available in the community. They include Narcotics Anonymous (NA), Ala-Teen, and Al-Anon. Most of these groups follow the 12-Step program used in Alcoholics Anonymous (AA). SMART Recovery and LifeRing Recovery are programs that do not use the 12-step approach. You can find support groups in your phone book. Expectations (prognosis) Drug abuse and dependence may lead to a fatal drug overdose. Some people start taking the drugs again after they have stopped. Relapses can lead to continued dependence. Complications The complications of drug abuse and dependence include: Bacterial endocarditis, hepatitis, thrombophlebitis, pulmonary emboli, malnutrition, or respiratory infections, caused by drug use by injection Depression Drug overdose Increase in various cancer rates; for example, lung and pharynx cancer are linked to nicotine use; mouth and stomach cancer are associated with alcohol abuse and dependence Infection with HIV through shared needles Problems with memory and concentration, for example with hallucinogen use, including marijuana (THC) Problems with the law General pharmacology
227 Relapse of drug abuse Call for an appointment with your health care provider if you are addicted to drugs and would like to get off of them, or if you have been cut off from your drug supply and are at risk of withdrawal. Most employers also offer referral services for their employees with substance abuse problems. Prevention Drug education programs may be helpful though none has proved effective in the long term.
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Chronopharmacology Chronopharmacology is the study of the interactions of biologic rhythms with medications;chronopharmacology is focused on 2 areas: 1. Biologic rhythm dependencies of medications and underlying mechanisms 2. Effect of timing pharmacotherapy on biologic time structure and relationships among rhythms. Circadian rhythm the regular recurrence in cycles of approximately 24 hours from one stated point to another, e.g., certain biological activities that occur at that interval regardless of constant darkness or other conditions of illumination. A biological rhythm is an adaptive phenomenon of both individuals and species relating to predictable changes in environmental factors linked to the rotation of the earth around its axis in 24 hours as well around the sun in 365 days. Circadian rhythms are endogenously driven by biological clocks found in single cells, flowers, animals and men and in which "clock genes" are expressed.
Where can our biological clock be found?

The word biological clock was being used long before the actual clock was found. It is a miniscule piece of the brain (20 000 cells in all) just above the optic chiasma (the place where the optic nerves are crossing). The suprachiasmatic nucleus (SCN). Because it is so close to the optic nerve it can get information directly from the eyes. In newborn babies this part of the brain is not yet ready; this explains why they do not have a clear daily rhythm yet. In old people brain cells die, also in this part, this explains why their rhythm often deteriorates. Especially when people are demented this can give problems.
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The place of the suprachiasmatic nucleus
Studies on the brains of people who died in hospitals (so that their brains could be frozen very soon after death) have shown that the SCN looks different during the night from what is looks like in the daytime and in autumn it is different from what it looks like in spring. Vasopressin is a protein that is best known because it works as a hormone influencing blood pressure (hence the name), it is also a neurotransmitter. It does not fall apart immediately after death. The presence of this substance can easily be demonstrated in the brain. It turns out to show much variation: the number of cell producing vasopressin is fifty percent higher during the day than during the night, and in autumn there are two and a half to three times more than in spring. In young people this variation is much bigger than in people older than fifty. These fluctuations coincide with other fluctuations, like the amount of sleeping hours per 24 hours - this is most in autumn and least in May/June. Testosterone is lowest in spring and rising toward autumn and low in the morning and high in the end of the afternoon (in young men, in older men it is more equal). The biological clock turns out not only to regulate sleeping and waking but also the functions connected with reproduction. For animals this is logical, their reproduction is seasonal, it is important that the young ones can find enough food at the moment they have to start finding their own food. The moment of birth does not need to happen at a time of abundance, but the moment of weaning has. Polar bears are born during the worst of seasons, the beginning of the polar winter, but when the young bears leave their den it is spring and when they start looking for their own food it is high summer. The cells of the SCN have each their own rhythm: when they are grown on a medium they continue to show that rhythm. (There even exist cells from other tissues that still show their 24-hours rhythm after being grown outside the body during 30 years!) The SCN gets its information from the eye, not from the rods and cones with which we see but from special cells in the ganglion layer. These specialised cells have discovered only very recently. General pharmacology
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Melatonin
Seasonal influences probably are caused by actions of the pineal gland, producing melatonin. In reptiles and birds the pineal is the so-called third eye, directly influenced by light. In mammals it is influenced through the eyes. When it gets dark the gland starts the production of melatonin, when it gets light again it stops. During longer nights more melatonin is produced. Probably melatonin influences the biological clock and this again influences the hypothalamus and through this the pituitary. The hormones produced here in turn influence metabolism and the sexual organs. The more melatonin the less activity in the SCN and the weaker the activity of the sexual organs. This explains why Inuit women have hardly any ovulations and menstrual cycle in winter (this is the reason why some people try to use melatonin as contraception pill). The question if humans have seasonal changes is difficult to answer. Our modern life style, holidays in summer etc make such possible differences quite invisible. Melatonin became very famous when it was discovered that it can be used against jetlag. In some countries it is freely available to be used against jetlag or as a healthy sleeping pill. To use it as a contraceptive would demand such high doses that one would immediately fall asleep - which works of course contraceptive too. Probably it is not a very good idea to fight jetlag with melatonin. Because many organs in our body have their own rhythm it could damage the balance of the many systems. Better use natural sunlight to adapt to the new day and night rhythm.
The circadian clock affects the daily rhythms of many psycholocial processes. This diagram depicts the circadian patterns of someone who rises early in the morning, eats lunch about noon and sleeps at night. Although circadian rhythms tend to be synchronized with cycles of light and dark other factors such as ambient temperature, meal times, stress and exercise can influence the timing as well.
231 It is possible to influence the biological clock directly, bur indirect methods are better: people working in nightshift sleep better when they work in the night under very strong lamps. Also Alzheimer patients who have lost the function of their biological clock for a big part will get their sleep and wake rhythm at least partly back if they are subjected to very strong light. They will also be less restless thanks to this light therapy. When people are subjected to other day-and-night-rhythms than the earthly 24 hours, they do not react well. People staying in space more than three months start sleeping badly, feel tired etc. On Mars the day is a little longer than on Earth, and the light is more yellowish. Our photoreceptors are mainly sensitive for the blue part of the spectrum. Chronobiologists think that long stays on Mars could be disastrous. A good argument to stop planning trips to Mars? The SCN is different in men and women - in women it is longer, in men more rounded. This means that it can have more connections in the brain of women (we do not know if this has a function). The biological clock has something to do with sexual preference too: male rats with a high testosterone prefer females at the end of the night but male partners in the first part of the night. These animals had 50% more cells producing vasopressin than usual, and given more or less melatonin their behaviour changed. The Dutch neurologist Swaab discovered in 1989 that homosexual men have a very big SCN. According to Swaab homosexual men do not have feminine brains, but they are really different, they are in a way a third gender.
Bacteria with a jetlag?

The fact that bacteria possess a biological clock makes the research easier. It is quite easy to cause mutations in bacteria. This makes it possible to find out how the system works. Several mutants have been found with a different circadian rhythm: some with 16 hours, others even 60 hours. This shows there exists a genetic basis for the clock. Today several genes are known to be responsible for the clock. One of the studies used a nice technique: the gene for luciferase (the enzyme causing light in some organisms) was built in in the genome of the bacteria under study. This made it possible to see with the naked eye if the clock was working: the bacteria would give light at certain times of the day. This also proved that the whole metabolism and not only photosynthesis is regulated by the cell clock. One more interesting aspect of this study is that bacteria must be able to see, to know light and darkness, so that they can adapt to the real day and night. In these organisms a compound cinnamon acid, was found, this is related to retinal, the compound in our eyes reacting on light. The difference between human and bacterium is much smaller than people like tot think! Also in other studies it was found that most genes in higher organisms can be found in bacteria.
The actual clock

A clock can be defined as a system that shows a regular and predictable effect. The motion of the earth around its axis and the route of the earth around the sun are clocks in this definition. We know mechanical clocks (the pendulum clock) and atomic clocks based on the regular oscillation of certain atoms. Mechanical clocks are not possible in living systems, atomic clock not probable. All lifes processes happen on the scale of molecules, mostly enzymes. Biological clocks are no exception. General pharmacology
232 Already for a long time mutants with different circadian rhythms have been known, proving that there exists a genetic basis. Much work has been done on the fruit fly Drosophila, which is popular with geneticists. This animal has a clear day-and-night rhythm. Mutants of the fly have been found with different lengths of their cycle. The flies leave their pupa always at the beginning of the day, but this also can be changed by such a mutation. In one study the gene of luciferase was added tot the clock-gene, after which the animals were periodically giving light with all of their body. This shows that all cells possess the clock mechanism. The molecular clock found in the fly is for the most part identical with that of the mouse (and other mammals, so also with ours). This means that the system must be at least 700 million years old (older than the common ancestor). In plants and fungi other genes are responsible for the clock, but the system is the same. This means that the biological clock must have evolved more than once. Het principe is altijd als volgt: The principle is always like this: a protein is produced following the scheme: Gene >> mRNA >> protein (this is the mechanism to construct proteins in all cells) The protein in this case has two characteristics: it is degraded after a certain amount of time (but always the same amount of time!) and it suppresses the expression of its own gene (this can be done by one protein or in combination with a second protein).If for instance the protein is degraded after 24 hours, the gene can always during some time every 24 hour produce the protein (until the moment there is enough of the protein again) . This can be the signal to start or stop certain processes in the cell
The biological clock of the fruitfly. The actual model of the biological clock, molecular clock of the fruit fly: a protein complex consisting of CLOCK and CYCLE connects with DNA causing the production of the proteins PER and TIM. A kinase (an enzyme) in the cell breaks down PER, but after some time there is enough TIM to build the PER/TIM complex before the PER is broken down. The protein complex PER/TIM turns the CLOCK/CYCLE complex off. After a certain time the PER/TIM complexes are broken down, after which the cycle can start again. The time needed to break down the PER/TIM complex decides the length of the cycle. Biological clocks in other types of organisms (like fungi, plants, bacteria) use the same
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principle using slightly different proteins.
This makes understandable that some mutants give a longer or shorter period: a protein that degrades slower or faster can be the result of a small change in the gene. If light has influence on the building or breaking down of the protein the clock can be adjusted by light. In continuous light or darkness the system will run in its own rhythm. Probably there are more proteins that have to cooperate to make the system run. There are still many questions about the exact working of the clock: how many proteins are really involved? How does the feedback system work exactly? How can the compound leave or enter the nucleus of the cell? Which processes are subjected to the clock? 40 years of hard work were needed to get some insight in the system. For a long time nobody believed that a clock based on proteins was possible because one of the fundamental characteristics of reactions of proteins is the fact that the speed of their reactions changes with the temperature. Cold blooded animals and plants have perfectly working clocks too, which means that the system is not depending on the temperature. Today we think we understand the system, but nobody can explain how it can be independent of temperature.
The day and night rhythm of a unicellular organism producing light (like Noctiluca causing the lighting of the sea during warm summer nights). Only during the night this creature produces clear light, not during the day. This also happens in continuous circumstances. The graphics shows that also other activities of this organism show a circadian rhythm.
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The system that is generating the circadian rhythms is better known as the internal clock, a neuronal network that has in his center the suprachiamatic nucleus (SCN) composed by neurones with an electrical activity, secretory activity, gene expression activity with a reactivity of about 24 hours. Because of this multilayered structure, the external synchronizer have only a modulating influence on the intenal clock. The main environmental synchronizer is the photoperiod ( the night/day alternance), sustained by melatonine, neurohormone produced by the pineal gland, influenced by the retinohypothalamic tract of the photic system. The photic perception is also present in blind people, and animal models demonstrated that this system is functionally independent from the perceptive visual system. Melatonin has also a central action: by an incompletely understood The human body is not only organized in space, anatomically, but it is also organized in time, in terms of biological rhythms. Circadian rhythms, and their alteration could be important determinants of morbidity and mortality. They may also be very important in influencing the responses to various medications. There are many unfavorable events early in the morning: Hemodynamic factors: the following are increased: BP and heart rate, stroke volume and cardiac output, total peripheral resistance, vascular tone, plasma volume, pulmonary arterial pressure, platelet agregability, blood coagulability, blood viscosity, serum cholesterol; the following are decresed: coronary blood flow, forearm blood flow, renal flow, glomerular filtration rate, urinary flow, fibrinolysis. Neuro-hormonal factors: the following are increased: autonomous tone, plasmatic concentrations of: norepinephrine, epinephrine, tyrosine, dopamine, prorenine, renine, angiotensin I, aldosterone, ACTH, cortisol, endogenous
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opioids; the following are decreased: serotonine, natriuretic peptid system, Na excretion, K excretion. In the first morning hours the physical and mental activity are increased, so that the shear stress of vascular atheroma is also increased, of sufficient magnitude to cause initial disruption of a stable atherosclerotic plaque. The exposure of naked intimal collagen and tissue factors in turn serve as foci for platelet aggregation, inflammatory mediators accumulation, and resultant thrombus formation around the disrupted plaque. The mutual interaction of these unfavorable factors is creating what the actual president of the International Society of Chronobiology, prof. Portaluppi was calling: a cardiovascular Twin Peaks.The temporal distribution of different diseases/disfunctions can be presented by the following figure imagined by Smolensky(12)(Figure 1). Figure 1. Worst of Times
The term Chronopharmacology has been introduced by HALBERG(7) in the 60s. The rhythmical functionality of the organism being evident is perfectly logical and demonstrated by the existence of a rhythmicity of his functions, as an exemple: parameters, that means of the normal values of the biological test, a fact that makes perfectly justified the desire that the administration of a drug to be as possible adequate to the evolution of the circadian rhythm determinants of the pathological processes(4, 8, 9). The modern Chronopharmacology consists not only in the study of the temporal variations of the kinetics, of the activity, of the efficacy and the toxicity function of the moment of the administration of the medication, as in
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the study of the possible modifications in the temporal structure of the organism in which the drug is administered(8-22). We live, although, in an era where the conservatorism of teaching and of the classical medical practice determine the attitude to overlook the temporal structure of the organism, trying to answer to questions of this kind: why, how, with what and in what dose, neglecting the question: when?. Thats why, not rarely, absolutely automatically, one consider that the effect of the medication is optimal if the level of the drug is maintained constant during the 24 hours, because, absolutely wrong, one consider that a constant concentration of a drug determines a constancy of the effect of the drug. This fact explains why the great majority of the therapeutical schemes, of drugs administration, as of technologies of drug production have the homeostatic aim of their blood and tisular constancy. But, knowing the temporal variability (ultradian, circadian, infradian, circaseptan, circatrigintan, circannual etc.) of the manifestations (for example, the intensity of the symptoms), the security of drug utilization constitutes the reason of a new approach of the therapy chronotherapy. Chronotherapy can be defined as a modality of optimization of the efficiency and security of the medications by temporal distribution of the drug administration on the 24 hours, so that to achieve an action of them synchron with the determinants the biological rhythms of the pathologic processes and/or with the tolerance of the patient to the adverse effects associated with them. Such a chronotherapeutic approach has been imposed in the case of the predictable risk of some medical severe events or of the predictable variation of the intensity of the symptoms of some diseases. Conventional medications can have a significant increase of the efficacy and security by concordant administration with the temporal structure. The first mention to such an optimization of the therapeutic effect was made in the 60s: the single morning administration of metilprednisolone reduces the risk of suppression of hypotalamo-hypophyseal-adrenal axis and, on the other hand, ameliorates the efficacy of his anti-inflammatory action. Later, many clinical studies, on large groups, have proved similar effects, the largest and the most quickly recognized example being the vesperal
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administration (in single dose) of the H2-receptor blockers having an superior efficacy and necessitating smaller doses for counteracting the nocturnal increase of the acid gastric secretion. Drug prescription must be realized with the aim of obtaining an optimal benefit/risk ratio (in principal), and secondary trying to realize the best cost/efficiency ratio, because it is now considered that in the third row, in the decreasing order of frequency, after the cardio-vascular diseases and the oncological ones are situated those secondary to medications, which affect almost 10% of the population. Chronopharmacology is ment also to restaure the perturbated temporal structure of an organism to resynchronize the biorhythms of this one by adequate therapeutical schedules. One can affirm that without an application of the chronotherapy principles one couldnt obtain the practical realization of the definition (created by a group of WHO experts) of the drug: any substance or product utilized or destinated to be utilized for modifying or the study of a physiological system or of a pathologic condition, in the interest of the subject to whom it is administered. Pharmacology includes pharmacodynamics (the study of the way by which a drug is working) and pharmacokinetics (the study of the evolution of the drugs is the organism). Its obvious that the two domains overlap, the response of the receptor situs being dependent on one side of the drug concentration at this level, and on the other side of the drug fate (that includes the absorbtion, the distribution, the metabolization and the elimination of this one). As an example, the rate of the dissolution of pH-dependent formula can differ substantially in the case that the medication is administered in the morning, when the acid secretion is reduced, and the local environment is basic, in comparison to the vesperal administration, when the basal acid secretion is increased, and the local environment is acid. Because at all these levels one can see the existence of a temporal variation, Reinberg(4), proposed 3 terms which implies their interdependence in chronopharmacology: chronoestesy, chronopharmacokinetics, chronoergy. Chronoestesy represent the sum of the temporal modifications in the absorbtion, the metabolisation and elimination of a drug. She describes the
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influence of the moment of the administration of a drug on the parameters that describe these processes in the terms of the absorbtion rate, the peak concentration of the drug (C max), of the time passed till obtaining the maximal concentration of the drug (E max), of the surface under the curve concentration time (AUC), of the half-time (T ) etc(8-22). Chronoergy represent the rhythmical modification of the organism response to a drug (his total effect), according to his chronokinetics and chronoestesy. The final aim of chronopharmacology is to study the calitative and/or cantitative termporal modifications of the drugs efficacy, for the optimization of their utilizations. One has demonstrated that all the steps of pharmacokinetics: absorbtion, transport, tissular diffusion, metabolisation, drug elimination have all rhythmical variations, with the above-mentioned periodicities. The rhythms associated to the free proportion of the drug, as the cellular functions from the sites of the drug action can have as result significant differences in the dependent of time efficacy of the therapy. It is also possible that the same active substance, contained in products of the different societies, can have different effects, in function of the moment of their administration, due to the their differences in the eliberation systems of this active substance, a fact that determine that the influences of the circadian rhythm on the kinetics and the effects of the individual forms of dosage and presentation are important to know(4, 6, 9, 10, 12-14, 17-20). So, factors that influence the action of the drugs are: a.) The drug and his characteristics: the chemical structure, dosage, the ratio between the distribution speed and the elimination and biotransformation speed, the distribution in the body and the fastening to tissues, the association with other drugs. b.) The organism and his characteristics: species, kind of nervous system and metabolism, age, sex, the way to administer, weight physiological or pathological condition all realize interconditionnings/interconnexions that have the shape of sinusoidal curves with different periodicities. For the therapeutic optimization it is mandatory to: to clear up the mechanisms of action and to prove scientifically some
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therapeutical indications; to indicate the optimal ways or respectively the optimal alternance of the ways of drug administration for obtaining the optimization of the therapeutic effect, concomitantly with: - maximal reduction of the side and toxic effects - the optimization of the rhythm of administration - the choose the most appropriate drug associations - to restore, by medication, the affected temporal structure of the organism. Such a chronotherapeutic approach is especially necessary: when the risk of disease or when the risk of apparition of some symptoms is known when the therapeutic window for a given medication is very narrow, close to toxicity when the toxicity of the drug is a factor of dose limitation when the kinetics or/and the effects are dependent of the moment of the administration when the aim of the hormonal treatment administration is to simulate the temporal schemes observed in healthy subjects when the effect of the drug can be obtained only by a time-modulated therapeutical modality. Nearly all functions of living creatures including man exibit significant daily variations. There are also temporal changes in receptors drug binding or transductional effects, as well as pharmacokinetic variations in absobtion, distribution, metabolism and elimination according to the moment of administration. So, it isnt surprising that the pharmacokinetics as well the effects and side-effects of drugs can vary significantly with the time of day as has been documented in many clinical studies. Thus time-or-day as to be regarded as an important factor to evaluate drug efficacy and the terapeutic window. Nearly all functions of the body, including those influencing pharmacokinetic parameters such as drug absorbtion and distribution, drug metabolism and renal elimination, show significant daily variations: these include liver
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metabolism, hepatic blood flow and the first-pass effect; glomerular filtration, renal plasma flow and urine volume and pH, blood pressure, heart rate and organ perfusion rates, acid secretion in the gastro-intestinal tract gastric emptying time. There is clear evidence that even dose/concentration-response relationships can be significantly modified by the time of day. Thus, circadian time has to be taken into account as an important variable influencing a drugs pharmacokinetics and its effects or side-effects. Circadian rhythms are now clearly demonstrated for the function of physiology and the pathophysiology of diseases. The efectivenesss and toxicity of many drugs vary depending on dosing time. Such chronopharmacological phenomena are influenced by not only the pharmacodynamics but also by the pharmacokinetics of medications. The underlying mechanisms are associated with 24 h rhythms of biochemical physiological and behavioral processes under the control of circadian clock. Thus, the knowledge of 24 rhythm in the risk of disease plus evidence of 24 h rhythm dependencies of drug pharmacokinetics, effects, and sefety constitutes the rationale for pharmacotherapy. Chronotherapy is especially relevant, when the risk and/or the intensity of the symptoms of disease vary predictably over time as exemplified by alergic rhinitis, arthritis, asthma, myocardial infarction, congestive heart failure, stroke and ulcer disease. Identification of a rhythmic marker for selecting dosing time will lead to improved progress and diffusion of chronopharmacotherapy. To monitor the rhythmic marker such as clock genes it may be useful to choose the most appropriate time of day for administration of drugs that may increase their therapeutic effects and/or reduce their side effects. Furthermore, to produce new rhythmicity by monitoring the conditions of living organs by using rhythmic administration of altered feeding schedules of several drugs appears to lead to the new concept of chronopharmacotherapy. Attention should be paid to the alteration of biological clock and consider it an adverse effect, when it leads to altered regulation of the circadian system whichis a serious problem affceting basic functioning of living organisms. One approach to increasing the efficiency of pharmacotherapy is administering
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drugs at times during which they are best tolerated. From a pharmaceutical point of views, the appplication of biological rhythm to pharmacotherapy may be accomplished by the appropriate timing of conventionally formulated tablets or capsules, or by using special drug delivery systems to synchronize drug concentrations to rhythms in disease activity. New technologies for delivery medications precisely in a time-modulated fashion by bedside or ambulatory pumps is developing to manage human disease(23,24). Due to advances in chronobiology, chronopharmacology, and global market constraints, the traditional goal of pharmaceutics (e.g. design drug delivery systems with a constant drug release rate) is becoming obsolete. However, the corner stone in the development or drug delivery systems that match the circadian rhythm (chronopharmaceutical drug delivery systems: Chr DDS) may be the availability to appropriate technology(6). It worth underline the fact that the realization, in the last decade, of different forms of presentation for the same drug, made possible his administration orally, cutaneous, nasal, parenterally, etc., the permanently growing possibility to utilize scheduled, extracorporeal and implantable pumps constitute elements of great utility in the future, being essential elements, of material support in realizing these principles of chronotherapy. It results, so, that the application of the therapeutical measures must have in mind on one part the temporal structure of the organism, the temporal susceptibility of this one to the drug, and on the other side to choose the optimal moment for the drug administration and his biodisponibility in conjunction to the one of the organism(25-33). The following data represent a summary of the actual proven data regarding the results of chronotherapeutic studies, as presented in Chronobiologie medicale, Chronotherapeutique Reinberg(4), but also with other data(2, 513, 17-20, 23, 24, 26-44). Alergology H1 receptor blockers (Mequitazine, Rimalan) maximal efficacy for the whole daily dose in the evening (even in those suffering from allergic rhinitis,
242
symptomatic in the morning. Anesthesics Bupivacaine, Lidocaine, Mepivacaine administred at 15.00 have a 2-4 times longer duration of action as compared with the administration at 7.00 or 19.00 Oncology Adriamicine (doxorubicine) and Cisplatin (Cis-DDP) The best clinical and biological tolerance: adriamicine i.v. administred at 06.00; cis-DDP i.v. administred at 18.00 without significant benefits regarding the efficacy by chronotherapy. 5-Fluoro-uracile (5-FU) In metastatic colo-recal cancer in perfusion by programmed pumps: the morning dose administred at 04.00 had an excellent tolerance for doses ranging from 5 to 8 g/m2/cycle; unchanged efficacy by chronotherapy 5-FU + Oxaliplatine (I-OHP) + folinic acid In metastatic colo-rectal cancer, in perfusion by programmed pumps: the maximal dose of 5-FU and folinic acid being programmed at 04.00 and the maximal dose of I-OHP being programmed at 16.00 were follwed by: excellent tolerability; no need for hospital management; significant amelioration of QOL ; 18% lesser financial value of the chronomodulated treatment. 6-Mercaptopurine in acute lymphoid leukemia in children: 2 times increase of the number of survivals by evening administration, compared to morning treatment with the same product, in the same dosage a model of oncological chronotherapy optimisatin. Cardiology It mandatory that we dont forget the morning fatal crossing Beta-blockers: Atenolol, Sotalol with reduced lipophylicity non-dependent effects regarding the temporal schedule of their
243
administration Metoprolol, Propranolol effects influenced by the temporal schedule of their administration. They are relatively inactive during the night, even when using formulations with extended release. Diuretics by administering the thiazidic diuretics in the morning (before 09.00) the risk of hypokaliemia is significantly decreased. Calcium antagonists: Nicardipine, Nitrendipine, Verapamil, Amlodipine, Diltiazem must be administred in the evening (they do not excessively decrease BP values during the night). Specially conceived systems (available in USA and canada: COER, CODAS: Covera-HS, Verelan-PM Anti-anginal drugs Diltiazem greater efficacy by morning administration, compared to the 12.00 a.m. administration in Prinzmetal angina Anticoagulants Aspirine recommended at bedtime (best effects, best tolerance. We will make a special reference for hypertension. Table 1. Time-Dependent Differences in the BP-Lowering Effect of Conventional Once-a-Day Drugs(17, 34) Medication (Authors) Dose (mg) Dosing Times (Conditions) Subjects (No. and Type) Differential Administration Time Effect on 24 BP Pattern
244
Benazepril (Palatini et al., 1993) 10 mg 9 a.m. vs. 9 p.m. (single dose) 10 EH 9 a.m. dose exerted greater BP-lowering effect. Duration of therapeutic effect shortened by 5h with 9 p.m. dosing. Ramipril (Myburgh et al., 1995) 2.5 mg 8 a.m. vs. 8 p.m. (4 weeks) 33 EH 8 p.m. dosing improved nocturnal BP-lowering effect. Enalapril (Witte et al., 1993) 10 mg 7 a.m. vs. 7. p.m. (single dose) 8 EH 7 a.m. dose significantly reduced daytime but not nighttime BP; 7 p.m. dose: stronger overnight and morning but no afternoon effect on BP. Quinapril (Palatini et al., 1992) 20 mg 8 a.m. vs. 10 p.m. (4 weeks) 18 EH No dosing-time difference on day-time BP; 10 p.m. dosing reduced nocturnal BP more than 8 a.m. dosing. Perindopril (Morgan et al, 1997) 4 mg 9 a.m. vs. 9 p.m. (4 weeks) 18 EH 9 p.m. dosing markedly lowered BP (particularly SBP) during nocturnal sleep but was associated with ~33% shortening of SBP and DBP-lowering effect during the 24h dosing interval. Captopril + HTZ
245
(Middeke et al., 1991) 25/12.5 mg 7 8 a.m. vs. 6-8 p.m. (3 weeks) 13 EH Evening dosing resulted in attenuation of daytime BP-lowering. Evening dose reduced BP during daytime (6 a.m. 6 p.m.) equal to that achieved by a q12h dosing schedule (equal to twice the dose/24h) of the combination medication. Diltiazem Retard (Kohno et al., 1997) 100 200 mg 8 a.m. vs. 7 p.m. (3 weeks ) 7 EH 8 a.m. dosing better reduced BP during nighttime sleep; 8 p.m. dosing exerted greater daytime BP-lowering effect and inhibition of morning BP rise. Isradipine (Portaluppi et al., 1995) 5 mg 8 a.m. vs. 8 p.m. (4 weeks) 16 RF 8 p.m. dosing best lowered both day and nighttime BP and normalized the non-dipping circadian BP pattern of renal patients. Doxazosin (Hermida, et al., 2004) 4 mg Morning vs. Bedtime (3 months) 91 EH Morning dosing exerted little nocturnal BP- lowering and had only minor effect on 24h mean BP. Bedtime dosing exerted full 24h BP control and, compared to morning dosing, several-fold greater reduction in 24h mean BP. Normalization of the circadian BP pattern is considered to be an important clinical goal of pharmacotherapy because it may slow the advance of renal injury and avert end-stage renal failure.
246
To aleviate/to abolish the morning surge is mandatory: theres a Twin peaks period (PORTALUPPI) during the morning hours: silent myocardial ischemia, angina pectoris, unstable pectoris, acute myocardial infarction (AMI), coronary spasm, pulmonary thromboembolism, ectopic beats, ventricular tachycardia, atrial flutter and fibrillation, paroxysmal supraventricular tachycardia, aortic aneurism rupture, spontaneous aortic dissection are all much more frequent in the morning hours (Figure 2). Its now possible to use either time-coordinated schedules of conventional antihypertensive drugs administration (see below) or products specially conceived for chrontherapy. Conventional antihypertensive drugs(35-44) Any BETA-BLOCKER should be administered in the morning CALCIUM-CHANNEL BLOCKERS WITH SUSTAINED RELEASE have a significant residual effect even after 24 hours: Amlodipine, Isoptin-RR, CALAN-SR, VERELAN-PM. When you administer them in the morning you can attenuate the morning peak, but, with the vesperal administration it is possible to induce a dipper profile: Isradipine, Verapamil-SR. ACEI: its preferable to administer them in the evening: - Ramipril (HOPE study) (To keep in mind: in the Heart Outcome Prevention Evaluation (HOPE) trial, the ACE inhibitor ramipril, which has an intermediate duration of action, was given at nighttime before sleep, this was found to be significantly associated with decreased cardiovascular morbidity and mortality inpatients at high risk for cardiovascular events). A HOPE substudy of 38 patients demonstrated significantly reduced 24-hr ABPM compared with office BP because of a more pronounced BP-lowering effect during nighttime. In addition, the night/day ratio was significantly reduced, raising the theory that some of cardiovascular benefits could be ascribed to the effects of nighttime and early-morning BP. HOPE study results: combined cardiovascular endpoint (cardiovascular mortality, MI, stroke) a decrease of 22% (p <0,001); cardiovascular mortality - a decrease of 26% (p < 0,001); stroke a decrease of 32% (p < 0,001);
247
- Benazepril - Enalapril (when we use at least 20 mg). Its preferable to use in the morning: Quinapril (its possible to have an excessive effect with a vesperal administration) Perindopril (for an effect longer than 24 hours) DIURETICS: Indapamide; Xipamide have both similar BP lowering effects in morning or evening administration -BLOCKERS: DOXAZOSIN determine the higest BP reduction when is administered in the morning. About of untreated patients with essential hypertension are dippers, about 20% are non-dippers. Non-dippers show a higher risk of target organ damage and worse cardiovascular outcomes than normal dippers, which suggests these could be a benefit to bringing down the nighttime blood pressure of non-dippers to a pattern more closely resembling normal dipping. All three groups: dippers, non-dippers and excessive dippers seem to get some benefit from chronotherapeutic dosing(45). Drugs specially conceived for CHRONOTHERAPY (true chronotherapeutic agents impart a dynamic element to drug delivery by providing larger drug concentrations during the critical morning period and smaller amounts during the nighttime, thereby minimizing the risk of excessive nocturnal BP drops): the vesperal administration offers an efficient 24 hours control, the highest reductions appearing in the critical hours of the morning their action begins after 4 hours maximal plasmatic levels around 10.00 a.m. N.B. These kind of preparations must be swallowed whole and not chewed, crushed, or split, as this may damage the drug delivery system and cause dose dumping. Chronotherapy of hypertension: special formulations marketed in USA: COVERA-HS; VERELAN-PM; CARDIZEM-LA; INNOPRAN-XL; and conventional medications dosed at bedtime versus upon awakening (FDA)(45). Endocrinology
248
ACTH indicated: morning administration, in phase with the morning peak of the ACTH secretion of the body: maximal stimulating effect in comparison with afternoon or evening administration. Corticosteroids Recommended: 2/3 of the dose in the morning, at awakening 07.00; 1/3 at 12.00 or 15.00 with the aim to restore the natural circadian rhythm of the corticosteroids. hCG (human chorionic gonadotropine) indicated in gonadal failure: the morning administration has the most powerful testicular answer, in comparison to afternoon or evening administration (the evening administration has no effects) Gn-RH in sterility due to hypothalamic failure a pulsatile administration, every 90 minutes, with programmed pumps is indicated; in hormono-dependent cancers of the breast and of the prostate is recommended an administration with a constant rate. Levo-thyroxine the peak of the physiologic secreton is around 08.00 so it is recommended to be administered at this hour. Testosterone the peak of the physiologic secreton is around 08.00 so it is recommended to be administered at this hour, as a patch. Gastro-Enterology H2-receptro blockers: Cimetidine, Famotidine, Nizatidine, Ranitidine a single bedtime administration is efficient in more than 80% of cases on 24 h. it is demonstrated that the control of gastric pH by i.v. infucsion make mandatory hourly administration of H2 receptor blockers, with greater doses during the night. Inhibitors of the proton pump: Lansoprazole, Omeprazole, Pantoprazole
249
a maximal dose of Omeprazole (40 mg) at awakening, before eating, can 99% inhibit the nocturnal gastric acidity. Other treatment schedules have worse results. Pneumology Nocturnal bronchial asthma The chronotherapy has the following targets: to increase te desired effects (a better control of te intensity of te frequency of the attacks) to reduce the adverse effects, especially tose of corticosteroids. Theophyllines with extended release It is recommended to deliver in the evening the entire dosage or 2/3 of this, the other 1/3 being administered in the morning. The result is characterized by a better efficacy and tolerance. Corticosteroids: 15.00 is the moment of administation characterized bya better efficacy and tolerance and the evening administration is poorly tolerated, with a diminished efficacy. B2Agonists Orciprenaline: best effcicacy is in the evening, during the night and early in the morning. During the day the efficacy is reduced. Salbutamol, Terbutaline Best results by administering 2/3 of the daily dose at 20.00, 1/3 at 08.00. Rheumatology Ancient AINS the digestive tolerance is better in the evening Recommended temporal schedule: Indometacin 20.00 h when the pain is worse in the morning; in the morning or at noon when the pain is worse in the evening. Ketoprofene recommended adminstration: 20.00 Tenoxicam
250
recommended adminstration: in the morning or at noon. And as final proofs we must remember many won battles by chronotherapy (2) the morning administration of the corticosteroids the asymmetrical dosage: a.m./p.m. of the corticosteroids in AddisonS disease the vesperal administration of HMG-CoAs antagonists the vesperal administration of theophylline with prolonged action and the asymmetric dosage a.m./p.m. of the beta-2-agonists in the treatment of bronchial asthma utilization of the melatonine and of the exposure to powerful light for the treatment of the symptoms of jet lag and of the perturbations of the sleep rhythm the vesperal administration of non-steroidal anti-inflamatory drugs in the treatment of rheumatoid poliartritis the vesperat administration of aspirin in the treatment of pre-eclampsia the vesperatl administration of ADH analogues for nicturia treatment the vesperal dosage of the cortico-steroids in Cushings disease the chronotherapy, before-mentioned, of HBP and of the ischemic heart disease. the oncologic chronotherapy. The fields of chronobiology and chronopharmacology are not only a new and modern branch of science, but that it stands on the shoulders of wonderful and insightful observations and explanations made by our scientific forefathers (29).
Chronobiology
Chronobiology studies the biological rhythms: - ultradian rhythms, shorter than a day - with a length, from thousandths of a second (like the pulses in neurons) or seconds (like the heartbeat) to the rhythm of about 90 minutes in our sleeping cycle (from REM-sleep to deep sleep)
251 - circadian rhythms, which last about one day, like the sleep-waking rhythm, the body temperature, but also our sensitivity to pain or alcohol, reaction time, levels of hormones in the blood etc. infradian rhythms, longer than a day. The most well known is de female cycle (often linked with the moon cycle, but there is no indication that this link is real (other mammals have rhythms of 3 weeks, or 9 days etc, only by accident humans have 28 days), Infradian are also year rhythms like bird migration. Also rhythms of a few days exist. Not only man, but also several animals (insects, but also some fungi!) have rhythms of some days. Humans have a rhythm of 5 - 9 days, which also occurs in complete isolation. Our week is not just a heritage of the Jewish culture, it has a biological basis. The immune system has a clear weekly rhythm.
Many physicians would prefer not to prescribe for pregnant women, the major concern being over teratogenicity of the drugs. The apprehension is not necessarily data driven, and is a cautionary response to the lack of clinical studies in pregnant women. In some cases, the use of drugs in pregnancy carries benefits that outweigh the risks. For example, high fever is harmful for the fetus in the early months, thus the use of paracetamol (acetaminophen) is generally associated with lower risk than the fever itself. Similarly, diabetes mellitus during pregnancy may need intensive therapy with insulin to prevent complications to mother and baby.[1]
Period of drug use

Pregnancy and development of fetus progresses through various changes. The period of one week from fertilisation to implantation of the fertilized egg is called preimplantation period. This is an 'all or none' period, .i.e. an insult can either cause death or complete recovery. The period from the 8th day to the end of 8th week (2nd month) is the period of organogenesis during which the organs are formed in the fetus. This is the most crucial time with regard to 'structural malformations' and concern over teratogenicity of drugs. From the 3rd month week to the end of 9 months is the period of fetal maturation. Intake of drugs during this period may modify the 'function' of the fetal organs rather than causing gross structural malformations in the fetus, for example, aminoglycosides can affect the functioning of kidneys and also the hearing mechanism.
The FDA has a categorization of drug risks to the fetus that runs from: "Category A" (safest) to "Category X" (known danger--do not use!) Category A: Controlled studies in women fail to demonstrate a risk to the fetus in the first trimester (and there is no evidence of a risk in later trimesters), and the possibility of fetal harm appears remote. e.g levothyroxine sodium, liothyronine sodium Category B: Either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women, or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester (and there is no evidence of a risk in later trimesters). e.g Penicillin, metronidazole, nitrofurantoin, cephalosporins, clindamycin, terbinafine, some macrolides e.g. azithromycin, erythromycin, Heparin (LMW), Acetaminophen, caffeine. General pharmacology
252 Category C: Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal or other) and there are no controlled studies in women, or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus. e.g Some aminoglycosides, chloroquine, quinolones, mebendazole, fluconazole, Heparin (conventional), betablockers, (dihydropyridine) calcium antagonists, furosemide, digoxin, methyldopa, : Aspirin, clonidine, rofecoxib, Tetanus toxoid, polio vaccine , BCG vaccine, hepatitis A vaccine, hepatitis B vaccine and rabies vaccine Category D: There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (e.g., if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective). Tetracyclines, gentamicin, tobramycin ACE inhibitors, ARBs, coumarins, thiazides, diltiazem, Carbamezapine, valproic acid, diazepam, lithium
Category X: Studies in animals or human beings have demonstrated fetal abnormalities, or there is evidence of fetal risk based on human experience or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant. e.g atorvastatin, diclofenac, ribavirin, warfarin.
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Classification of a few important drugs/vaccines

Antibacterial agents
Category B : Penicillin, metronidazole, nitrofurantoin, cephalosporins, clindamycin, terbinafine, some macrolides e.g. azithromycin, erythromycin Category C : Some aminoglycosides, chloroquine, quinolones, mebendazole, fluconazole Category D : Tetracyclines, gentamicin, tobramycin
Cardiovascular drugs

Category B : Heparin (LMW) Category C : Heparin (conventional), beta-blockers, (dihydropyridine) calcium antagonists, furosemide, digoxin, methyldopa Category D : ACE inhibitors, ARBs, coumarins, thiazides, diltiazem
Central nervous system drugs

Category B : Acetaminophen, caffeine Category C : Aspirin, clonidine, rofecoxib Category D : Carbamezapine, valproic acid, diazepam, lithium vac
Vaccines
Category C : Tetanus toxoid, polio vaccine , BCG vaccine, hepatitis A vaccine, hepatitis B vaccine and rabies vaccine.
Regardless of the pregnancy category or the presumed safety of the drug should be administered during pregnancy unless it is drug, no clearly needed and the potential benefits outweigh potential harmfetus. During pregnancy, no woman should consider taking the to any drug, legal or illegal, prescription or nonprescription, unless the drug is prescribed or recommended by health care provider. Smoking or drink the primary any type of alcoholic beverage also carries risks, such birth weight, premature birth, and fetal alcohol syn Children born of mother low as drome. using addictive drugs, as cocaine or heroin, often are born with antion to the drug abused by the mother such addic Age
The age of the patient may influence the effects of a drug. Infants and children usually require smaller doses of a drug than adults do. Immature organ function, particularly the liver and kidneys, can affect the ability of infants and young children to metabolize drugs. An infants immature kidneys impair the elimination of drugs in the
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urine. Liver function is poorly developed in infants and young children. Drugs metabolized by the liver may produce more intense effects for longer periods. Parents must be taught the potential problems associated with administering drugs to their children. For example, a safe dose of a nonprescription drug for a 4-year-old child may be dangerous for a 6-month-old infant. Elderly patients may also require smaller doses, although this may depend on the type of drug administered. For example, the elderly patient may be given the same dose of an antibiotic as a younger adult. However, the same older adult may require a smaller dose of a drug that depresses the central nervous system, such as a narcotic. Changes that occur with aging affect the pharmacokinetics (absorption, distribution, metabolism, and excretion) of a drug. Any of these processes may be altered because of the physiologic changes that occur with aging. Table 1-3 summarizes the changes that occur with aging and the possible pharmacokinetic effect.

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1 Chapter I IN O U TIO TR D C N

3 Clove oil: It relieves pain

Plasma drug conc. (g/ml

[AUC] oral/ (Dose)oral Absolute bioavailability = [AUC]iv/(Dose)iv

Dose administered by IV route Apparent volume of distribution (Vd) = Plasma concentration

Organ of metaboli sm Liver Lungs

Phenobarbitone, paracetamol Nicotine

71 4. NADPH to Cyt P450

Drug CYP eR-Ase CYP Fe+3

Drug OH CYP Fe+3 Drug OH e-

CYP Fe+2 Drug O2 O2 CYP Fe+2 Drug

Electron flow in microsomal drug oxidizing system

for example phenobarbitone

72 Aromatic ring ----> phenol

for example phenytoin Oxidation at S or N

sulfoxide for example chlorpromazine In two steps oxidative dealkylation is possible

for example 5-hydroxytryptamine

73 Alcohol dehydrogenase - in liver, kidney, lung

for example aspirin to salicylic acid Amides to amine and acid

For example procainamide

basis. E.g. oral anticoagulants affected by phenytoin

small circulating reservoir.

Desirable beneficial effect (Therapeutic effect)

Undesirable effect (Adverse effect)

Expected undesirable effect effect

Secondary Side effect

Second messengers or signaling path way

stimulates adenylyl cyclase and increase cAMP( adrenergic receptor)

This inhibits adenylyl cyclase and decrease cAMP(2 adrenergic receptor)

longer respond to 2 adrenoceptor agonist, like salbutamol.

In endogenous depression there is down-regulation of -adrenoceptors (with concomitant up-regulation of -

115 Cause immune response

124 Chapter X HOW DRUG EFFECTS CAN BE MEASURED

ED50 1.6 Log dose

100 (MR) % R e s p o 50 n s e ED50A Log dose

No. Of Cats Shown Cardiac Arrest

B No. Of Cats Shown Cardiac Arrest

No. Of Cats Shown Cardiac Arrest

LD1-ED99 SMF = ED99 CERTAIN SAFETY FACTOR (CSF) X100

Frequency (No. Of Subjects Responding)

Plama conc: in ng/ml of digoxin

100 Cumulative %. Of Cats Showning 50 Cardiac Arrest

XYZ Log dose

patient on different occasions have been observed. unchanged in urine.

Inhibit prostaglandin synthesis

Acts via opioid receptors

Double analgesic effect

Inhibit prostaglandin synthesis

Inhibit prostaglandin synthesis

167 (1) Trimethoprim Sulfamethoxazole

Inhibit dihydropteroate synthase enzyme and inhibit folic acid synthesis

Inhibit dihydro folate reductase and inhibit folic acid synthesis

Bactericidal (2) Levodopa

Carbidopa inhibits the peripheral decarboxilase enzyme

of the component drugs.

presence of the other

Mixture Thiopentone + suxamethonium

182 Interactions secondary to drug-induced alterations of fluid and electrolyte balance.

Primary drug Digoxin Lignocaine

Interacting drug effect Diuretic-induced hypokalemia

Result of interaction Digoxin toxicity Antagonism of

antiarrhythmic effects Antagonism of diuretic

Diuretics NSAID-induced salt Tubocurarine Lithium and water retention