Age-associated stereoselective alterations in hexobarbital metabolism

This clinical investigation was designed to study the influence of age on stereoselective drug disposition using hexobarbital as a model marker. The disposition of hexobarbital enantiomers was investigated in 10 young and 10 elderly, healthy male volunteers. Mean oral clearance (+/- SD) of d-hexobarbital (1.9 +/- 0.5 vs. 1.7 +/- 0.3 ml/min/kg; P greater than 0.05) did not differ significantly between the young and elderly subjects, respectively. However, despite wide intersubject variability, l-hexobarbital mean oral clearance (+/- SD) was approximately twofold greater in the young than in the elderly subjects (16.9 +/- 11.9 vs. 8.2 +/- 3.2 ml/min/kg; P less than 0.05). This resulted in a significantly greater enantiomeric oral clearance ratio in the young when compared with the elderly subjects (8.3 +/- 3.4 vs. 4.7 +/- 1.4; P less than 0.01). No significant difference (P greater than 0.05) in pharmacologic response after hexobarbital administration was found between the two groups. Demonstration of an age-related preferential decline in metabolism of one enantiomer over another has not been reported previously for any racemic drug in animals or humans.

The pharmacokinetics of oral isradipine in normal volunteers

The pharmacokinetics and relative bioavailability of oral isradipine, a dihydropyridine calcium channel blocking agent, were determined in 42 normal male volunteers participating in two separate studies. Eighteen of the subjects received 2.5-, 5-, and 10-mg oral doses of isradipine solution (Study 1). The remaining 24 subjects received four 2.5-mg capsules, one 10-mg capsule, and 10 mg of isradipine as an oral solution (Study 2). Venous blood samples were obtained prior to and at frequent intervals after administration of each dose form. Plasma isradipine concentrations were measured by radioimmunoassay. No significant dose effect occurred with respect to any pharmacokinetic parameter except AUC and Cmax in Study 1. In Study 2, Cmax, tmax, and MRT were significantly different after the solution compared with the capsular formulations. The respective pharmacokinetic parameters (mean +/- SD) for the 10-mg solution and 10-mg capsule in Study 2 were time to maximum concentration, 0.40 +/- .28 and 1.57 +/- 0.44 hours; oral clearance, 284.9 +/- 105.3 and 317.0 +/- 138.4 L/hr; elimination half-life, 5.36 +/- 1.8 and 6.63 +/- 2.4 hrs, respectively. Headache, dizziness, and tachycardia were the most frequent adverse effects in both studies.

Phenobarbital induction and acetaminophen hepatotoxicity: resistance in the obese Zucker rodent

The obese Zucker rodent appears to lack a significant induction response after phenobarbital pretreatment. Induction of the hepatic cytochrome P-450 system with phenobarbital is known to enhance acetaminophen hepatotoxicity. The purpose of this study was to evaluate the influence of phenobarbital enzyme induction on acetaminophen hepatotoxicity in the obese and lean Zucker rodent. A preliminary study was performed evaluating the pharmacokinetics of acetaminophen in both the obese and lean Zucker rats. Data were utilized to calculate appropriate loading doses of acetaminophen during the subsequent hepatotoxicity study. Phenobarbital enzyme-inducing regimens were administered p.o. to achieve similar steady-state phenobarbital plasma concentrations. Control rats received appropriate placebo solutions. Serum hepatic transaminase enzymes and histologic evidence of hepatocellular necrosis were utilized to evaluate hepatic damage after p.o. administration of 1300 mg of acetaminophen to both obese and lean Zucker rats. Obese Zucker control animals had approximately 2.5 times the total hepatic glutathione content compared to their lean control (164.9 +/- 43.2 vs. 65.3 +/- 18.4 mumol/whole liver). Obese Zucker animals receiving only acetaminophen showed a trend toward a reduced incidence of hepatocellular necrosis compared to similarly treated lean littermates. Obese Zucker rodents pretreated with phenobarbital had an even more pronounced resistance to acetaminophen-induced hepatocellular necrosis (P less than .01) when compared to similarly treated lean littermates. Thus, acetaminophen hepatotoxicity is reduced in the obese Zucker rat and pretreatment with phenobarbital offers further protection against hepatocellular damage. We suggest that the previously unrecognized increase in hepatic glutathione plays a major role in the resistance of the obese Zucker rat to acetaminophen hepatotoxicity.

Influence of obesity on drug disposition

Physiologic changes associated with obesity and their effects on the distribution, protein binding, metabolism, and renal excretion of drugs are described. Changes in the volume of distribution correlate with drug lipophilicity. Drugs that have a high affinity for adipose tissue have an increased volume of distribution, whereas the distribution of drugs that have low partition coefficients is not altered substantially. Albumin and total protein concentrations are comparable in lean and obese subjects, but concentrations of alpha 1-acid glycoprotein are increased. Consequently, protein binding of acidic drugs is unchanged, but the free fraction of basic drugs may be decreased. Changes in hepatic drug clearance are complex. Phase 1 reactions and acetylation, a Phase 2 reaction, appear to be unaffected by obesity, but activity of Phase 2 glucuronidation and sulfation pathways is enhanced. Available physiologic and pharmacokinetic data on the effect of obesity on systemic clearance of highly extracted drugs are conflicting. Both glomerular filtration and tubular secretion appear to be increased in obese individuals, and tubular secretion may be disproportionately increased compared with filtration. Clearance of drugs that depend on glomerular filtration for elimination is consistently higher in obese subjects. Differences among patient populations, other conditions associated with obesity, and the small study populations described to date may account for some discrepancies in reported results. Awareness of the physiologic effects of obesity is essential for ensuring appropriate drug therapy in obese patients.

Pentobarbital pharmacokinetics in patients with severe head injury

Intravenous administration of high-dose pentobarbital has been proposed as a treatment for elevated intracranial pressure refractory to other measures in brain-injured patients. The purpose of this clinical study was to examine the pharmacokinetics of high-dose continuous intravenous infusion of pentobarbital in this critical care setting. Six patients received a 25-34 mg/kg intravenous loading dose followed by a 1-3 mg/kg/h continuous infusion for 61-190 hours. Dosing rates were adjusted based on the patient's clinical status. The mean clearance was 0.72 ml/min/kg, with a volume of distribution (Vd) of 1.03 L/kg and a terminal half-life of 19.1 h. Considerable variation in individual patient parameters was observed. In addition, a change in clearance was suggested in patients requiring a longer infusion duration.

The evaluation of creatinine clearance in spinal cord injury patients

The parameters of age, height, weight, serum creatinine and 24-hour urinary creatinine production were measured in 101 consecutive spinal cord injury patients (79 men and 22 women, 43 quadriplegics and 58 paraplegics) admitted to a rehabilitation hospital. Creatinine production was significantly lower than that of age and sex-matched hospitalized controls, upon whom commonly used nomograms for evaluation of endogenous creatinine clearance are based. Therefore, these nomograms grossly overestimate the creatinine clearance in paralyzed patients, which often results in aminoglycoside overdosage. Regression analysis identified the interval since injury and age as important determinants of creatinine production. We propose 2 simple equations and nomograms that should allow more accurate prediction of creatinine clearance in spinal cord injury patients.

Renal function in the obese Zucker rat

The hyperphagic, genetically obese Zucker rat (fa/fa) exhibits both a greater kidney size and a progressive, premature glomerular sclerosis. In the present study, glomerular filtration rate (GFR), effective renal plasma flow (ERPF) and renal tubular function were evaluated during study 1 in lean Zucker (FA/-), fa/fa, and lean Sprague-Dawley (S-D) rats. The GFR as measured by renal inulin clearance (ClIN) was not significantly different (P greater than 0.05) between S-D (1.36 +/- 0.18 ml/min) vs FA/- (1.36 +/- 0.33 ml/min) and FA/- vs fa/fa (1.25 +/- 0.42 ml/min). The ERPF as measured by renal p-aminohippurate (PAH) clearance (ClPAH) also was not significantly different between S-D (3.98 +/- 0.80 ml/min) vs Fa/- (3.71 +/- 0.81 ml/min) and Fa/- vs fa/fa (3.34 +/- 1.60 ml/min). There was a significant difference (P less than 0.05) in the renal tubular transport maximum (Tm) of PAH between S-D (2.23 +/- 0.40 mg/min) and Fa/- (1.64 +/- 0.63 mg/min) groups but not between Fa/- and fa/fa (1.29 +/- 0.61 mg/min) groups, indicating a strain effect in organic anionic renal transport. The Fa/- vs fa/fa comparisons were significant when GFR, ERPF and Tm were corrected for total body or kidney weight. In a second group of animals (study 2), GFR (as reflected by creatinine clearance [Clcr]) and histologic studies were performed in Fa/- and fa/fa rats. Clcr values were significantly higher in the fa/fa (2.10 +/- 0.44 ml/min) vs Fa/- (1.68 +/- 0.17 ml/min). Histologic studies in group 2 demonstrated no remarkable differences between Fa/- and fa/fa rats. These results suggest wide interanimal variation in obesity associated changes in renal function and possibly pathology in the fa/fa rat.

Altered drug-serum protein binding in the genetically obese Zucker rat

Drug-serum protein binding was evaluated in genetically obese Zucker rats, their lean littermates, and lean Sprague-Dawley rats. The free fraction (fp) of phenytoin was significantly higher in the obese rat (fp = 0.177) compared to its lean littermate (fp = 0.136), apparently due to displacement by free fatty acids. Conversely, diazepam and propranolol fp values were decreased in the obese Zucker rat (fp = 0.107 and fp = 0.122, respectively) compared to the lean Zucker rat (fp = 0.140 and fp = 0.174, respectively). Evidence strongly suggests that the increased binding of propranolol was not due to elevations in the serum concentrations of alpha1-acid glycoprotein (as is the case in the human obese population). Rather, the decreased fp for both diazepam and propranolol was a result of increased lipoprotein partitioning. Strain differences between the lean Zucker rat and lean Sprague-Dawley rat were also evident, with serum binding of the Sprague-Dawley rat more closely resembling the obese Zucker rat.

Influence of high-dose pentobarbital on theophylline pharmacokinetics: a case report

The effect of high dose pentobarbital coma therapy on the total body clearance of theophylline (CLT) was evaluated in a neurosurgical patient. Preinduction and induction CLT were 4.22 and 8.02 L/h, respectively, which represented a 95% increase in the CLT as a consequence of pentobarbital therapy. Although barbiturates have been shown to induce hepatic microsomal enzymes, previous reports minimize their effect on CLT in humans. This case report demonstrates remarkable alterations in the CLT as a result of high doses of pentobarbital, necessitating the need for substantial dosage adjustments of theophylline.

Pharmacokinetics of calcium-entry blockers

Effective use of drugs in therapy depends not only on clinical acumen but also on the availability of relevant pharmacokinetic and pharmacodynamic data. Such information assists in development of safe dosing regimens, prediction of abnormal handling of drugs in states of disease and disorder and anticipation of drug interactions. For the calcium-entry blocking agents now available in the United States (verapamil, nifedipine and diltiazem), these data appeared well after clinical patterns of use evolved. Nonetheless, their relevance continues to be demonstrated by the dependence of each agent on intact liver blood flow and function for normal rates of elimination; by the nonlinear kinetic characteristics for verapamil and diltiazem (and probably for nifedipine, as well) and the derivative implications for decreased dosing frequency requirements; and by observations now appearing on the relation between plasma drug levels and drug effects, both therapeutic and toxic. Such data are discussed herein, with emphasis on those aspects that impact on the clinical use of the calcium-entry antagonists.

Hibernation "trigger" alters renal function in the primate

Macaque monkeys acclimatized to a restraint chair were fitted with indwelling venous and urinary catheters. After basal rates of urine production and creatinine clearance were determined, a 50 mg dose of plasma dialysate albumin fraction obtained from the woodchuck was administered intravenously in a total volume of 2.5 ml. Plasma fractions were collected during the winter interval of hibernation (hibernation "trigger" or HT), or during the summer active (SAWA) period. Although the SAWA fraction exerted no effects on renal function, HT caused a significant reduction in creatinine clearance. In addition, a tendency toward reduced urine flow and creatinine production occurred following the HT infusion. These findings suggest that over and above the hypothermia, aphagia and opioid-like behavioral depression induced by HT, the albumin fraction (HT) present endogenously in the woodchuck during winter torpor, exerts a direct action on the kidney of the primate, possibly on the mechanisms underlying glomerular filtration and the tubular reabsorption process.

Effects of phenobarbital and SKF-525A on in vitro hepatic metabolism of verapamil and nifedipine

Both verapamil and nifedipine are first-generation calcium-entry antagonist drugs which are eliminated by hepatic metabolism. To evaluate the effects of enzyme induction and suppression on the biotransformation of these compounds, liver homogenate fractions were prepared from male Fisher (F344) rats, which were either untreated, or injected intraperitoneally with phenobarbital or with SKF-525A prior to sacrifice. Known concentrations of verapamil or nifedipine were incubated with the 9,000 g supernatant, and the quantity of unchanged drug remaining after 10 min was measured. SKF-525A pretreatment significantly decreased the elimination (disappearance) rate of both calcium-entry antagonist compounds. Phenobarbital increased the rate of disappearance of verapamil, but had no effect on that of nifedipine. Difference spectra of hepatic microsomes to which verapamil had been added revealed a concentration-dependent, saturable interaction between drug and enzymes with spectral changes characteristic of "type I' substrates for cytochrome P-450 monooxygenase(s). The spectral characteristic of microsomes to which nifedipine was added could not be determined because of drug absorption at 350-500 nm. These data imply that verapamil metabolism is mediated by the cytochrome P-450 monooxygenase(s), and that nifedipine metabolism likely involves hepatic enzyme systems other than those known to be induced by phenobarbital.

Phenobarbital in the genetically obese Zucker rat. I. Pharmacokinetics after acute and chronic administration

The pharmacokinetics of the enzyme inducer, phenobarbital, was evaluated in genetically obese and lean Zucker and lean Sprague-Dawley rats. The volume of distribution of phenobarbital in obese Zucker rats was larger (0.416 liter) than for lean Zucker (0.299 liter) or Sprague-Dawley rats (0.312 liter). Standardizing the volume of distribution for total body weight in the obese and lean Zucker and lean Sprague-Dawley rats resulted in similar volume terms. Intra- and inter-strain differences in phenobarbital clearance were observed between the obese and lean Zucker (11.9 and 14.1 ml/hr, respectively) and lean Sprague-Dawley rats (23.0 ml/hr). Greater differences in phenobarbital clearance were observed when clearance was corrected for body weight. Whether comparing the absolute or standardized pharmacokinetic data, lean and obese Zucker rats will exhibit 2- to 3-fold higher phenobarbital plasma concentrations after administration of a standard 75- to 100-mg/kg enzyme-inducing regimen relative to Sprague-Dawley rats. Pharmacokinetic parameters from the single dose study were used to calculate appropriate phenobarbital doses (21-58 mg/kg/12 hr) to achieve similar steady-state phenobarbital plasma concentrations after chronic oral administration in all three groups of rats. Steady-state phenobarbital clearance values were not significantly different from clearance values after single dose administration in each group of rats. The dramatic intra- and inter-strain alterations in phenobarbital disposition demonstrated in this study explain the high mortality reported in Zucker rats after administration of traditional enzyme induction doses of phenobarbital. Differences in phenobarbital disposition should be considered in enzyme induction studies.

Phenobarbital in the genetically obese Zucker rat. II. In vivo and in vitro assessments of microsomal enzyme induction

In vivo and in vitro alterations in drug metabolism and the extent of enzyme induction of the hepatic microsomal cytochrome P-450 system were evaluated in obese and lean Zucker and lean Sprague-Dawley rats. Phenobarbital enzyme-inducing regimens were administered p.o. to achieve similar steady-state phenobarbital plasma concentrations. Control rats received p.o. placebo solution. No significant intra- or inter-strain differences in antipyrine clearance (milliliters per hour) or apparent volume of distribution (liters) were observed between the placebo-treated lean Sprague-Dawley, lean Zucker and obese Zucker rats. Intra- and inter-strain differences in hepatic microsomal protein and cytochrome P-450 content were observed. Compared to placebo, antipyrine clearance (milliliters per hour) after chronic phenobarbital pretreatment was increased in the Sprague-Dawley (198%) and lean Zucker rats (131%), but not significantly altered in the obese Zucker rats. Similarly, increases in hepatic weight, whole liver microsomal protein and cytochrome P-450 content were also observed in the Sprague-Dawley (34, 124 and 352%, respectively) and the lean Zucker rats (24, 96 and 249%, respectively). However, no significant alterations in these parameters were observed in the obese Zucker rats after phenobarbital treatment. Results from these in vivo and in vitro studies implicate alterations in drug metabolism and genetic differences in cytochrome P-450 content in Zucker rats relative to the Sprague-Dawley strain. Obese Zucker rats failed to exhibit a significant induction response after phenobarbital pretreatment.

Serum protein binding and the role of increased alpha 1-acid glycoprotein in moderately obese male subjects

Serum protein and lipid concentrations as well as the serum protein binding of propranolol, diazepam and phenytoin were measured in normal weight and obese volunteers. Concentrations of alpha 1-acid glycoprotein (AAG) in the obese subjects were double that of the lean controls. Conversely, concentrations of high density lipoproteins (HDL) were decreased in the obese group. The serum binding of propranolol was increased in the obese subjects and correlated with serum AAG concentrations. Diazepam binding was slightly decreased in the obese as a result of lower serum albumin concentrations and elevated free fatty acids. The binding of phenytoin was comparable in all of the volunteers. These findings point out some of the complex pathophysiologic changes associated with obesity which may in turn influence drug disposition and hence drug therapy in the obese patient.

Effects of hemodynamic changes on the elimination kinetics of verapamil and nifedipine

This study used a steady-state approach to evaluate the relationships between the pharmacodynamic and pharmacokinetic characteristics of nifedipine and verapamil. In anesthetized and instrumented dogs, i.v. bolus/infusion dosing regimens were used for each drug to achieve and maintain stable drug concentrations in four different ranges rapidly. For both compounds, increases in doses were associated with disproportionate higher plasma drug concentrations, greater hemodynamic effects and significant reductions in systemic drug clearance. Progressive increases in the dose of nifedipine produced reductions in arterial pressure and reflex augmentation in cardiac output, together with decreases in calculated hepatic plasma flow which closely paralleled the decline in mean aortic pressure. Increasing doses of verapamil also resulted in decreased hepatic plasma flow, which was associated with both systemic hypotension and drug-induced decreases in cardiac output. These data imply that the hemodynamic effects of both nifedipine and verapamil result in changes in hepatic plasma flow which, in turn, result in significant alterations in systemic drug clearance. In this experimental model, the calculated hepatic plasma flow and observed systemic clearance values for nifedipine and verapamil were closely related to concentrations of the respective drugs in plasma.

Clinical evaluation of the Abbott TDx fluorescence polarization immunoassay analyzer

The Abbott TDx fluorescence polarization immunoassay (FPIA) system was evaluated and compared with well-established enzyme multiplied immunoassay technique (EMIT) and radioimmunoassay (RIA) methods utilizing five high-volume drug assays including theophylline, gentamicin, phenytoin, phenobarbital, and digoxin. These drug assays were evaluated for precision, calibration stability, specificity, and accuracy. Within-run precision studies utilizing control samples (n = 20) in the subtherapeutic, therapeutic, and toxic ranges resulted in coefficients of variation (CV) of less than 4.0% for the theophylline, gentamicin, phenytoin, and phenobarbital assays and of less than 9.5% for the digoxin assay. Between-run precision studies based on an initial TDx calibration curve over a 2-3 week period yielded CVs of less than 8% for all five drug assays. Cross-reactivity of the FPIA gentamicin assay with concurrently used aminoglycosides such as tobramycin and amikacin was less than 0.1%, and interference due to hemolysis and lipemia was negligible. Highly icteric specimens resulted in clinically significant decreases in theophylline and phenytoin concentrations, but this problem can be corrected by subtraction of blank intensity values. Comparison of the FPIA method with the EMIT and RIA methods indicated an extremely good analytical correlation (r greater than 0.97) for all five comparisons. The Abbott TDx FPIA system offers significant advantages in calibration and reagent stability, and greater sensitivity in the low drug concentration ranges while maintaining accuracy and precision comparable with those of established EMIT and RIA procedures.

Influence of smoking on serum protein composition and the protein binding of drugs

The influence of smoking an alpha 1-acid glycoprotein (alpha 1-AGP) and serum albumin concentrations and the protein binding of phenytoin and propranolol in healthy volunteers was investigated. alpha 1-AGP concentrations were found to be statistically different (P less than 0.05) in the smokers (mean = 84.3 mg dl-1) versus non-smokers (mean = 62.8 mg dl-1). There was a trend for lower serum albumin concentrations and lower fraction unbound of propranolol in the smokers. Smoking did not affect the protein binding of phenytoin.

Clinical pharmacokinetics of verapamil

Verapamil is widely used in the treatment of supraventricular tachyarrhythmias as well as for hypertension and control of symptoms in angina pectoris. Unlike other calcium antagonists, detailed pharmacokinetic data are available for verapamil. Plasma concentrations of verapamil appear to correlate with both electrophysiological and haemodynamic activity after either intravenous or oral drug administration, although considerable intra- and intersubject variation has been found in the intensity of pharmacological effects resulting at specific plasma drug levels. Verapamil is widely distributed throughout body tissues; animal studies suggest that drug distribution to target organs and tissues is different with parenteral administration from that found after oral administration. The drug is eliminated by hepatic metabolism, with excretion of inactive products in the urine and/or faeces. An N-demethylated metabolite, norverapamil, has been shown to have a fraction of the vasodilator effect of the parent compound in in vitro studies. After intravenous administration, the systemic clearance of verapamil appears to approach liver blood flow. The high hepatic extraction results in low systemic bioavailability (20%) after oral drug administration. Multicompartmental kinetics are observed after single doses; accumulation occurs during multiple-dose oral administration with an associated decrease in apparent oral clearance. Norverapamil plasma concentrations approximate those of verapamil following single or multiple oral doses of the parent drug. Because of the complex pharmacokinetics associated with multiple-dose administration and the variation in individual patient responsiveness to the drug, 'standard' dosing recommendations are difficult to determine; use of verapamil must be titrated to a clinical end-point. Further, the potential for alteration in verapamil's disposition by the presence of hepatic dysfunction or cardiovascular disorders which result in altered hepatic blood flow is only now becoming apparent. A potentially toxic interaction has been reported between verapamil and digoxin, in which renal excretion of the glycoside is impaired, but the true clinical significance of this remains debatable. Combination therapy with verapamil and beta-adrenoceptor blocking compounds has been advocated by some investigators, but may be hazardous because of the additive negative inotropic and chronotropic effects inherent in both agents.

Serum alpha 1-acid glycoprotein and the binding of drugs in obesity

Although clinically relevant, drug-protein interactions in the morbidly obese population have not been studied thoroughly. The objective of this study was to evaluate serum chemistry profiles and the degree of serum protein binding of propranolol, diazepam and phenytoin in the serum of four female, morbidly obese (greater than 190% of ideal body weight) and eight control female subjects. Serum triglyceride concentrations were higher and high-density lipoproteins were lower in the obese subjects than in the control group. Serum albumin and total protein concentrations in the obese were not different from controls. Unexpectedly, alpha 1-acid glycoprotein concentrations were doubled in the obese subjects (mean obese value 121 mg/100 ml vs 62.9 mg/100 ml for the control subjects). Obese subjects had a mean fraction unbound (fu) for propranolol of 0.086, which was significantly different from the controls (fu = 0.123). The binding of diazepam was decreased slightly in the obese subjects. The binding of phenytoin was similar in both groups. The altered serum chemistry of obesity may play a significant role in the drug management of the obese patient by altering drug-protein interactions.