Metabolism of drugs and other xenobiotics in the gut lumen and wall

First-pass effect: significance of the intestine for absorption and metabolism

The occurrence of low systemic availability due to significant metabolism or poor absorption of orally administered drugs has been well recognized. Three rate controlling factors affecting the oral absorption: unstirred water layer, membrane limitation, or flow limitation, have been identified. These are much affected by the physicochemical properties of the drug: pKA, water/lipid solubility, structural mimicry to endogenous substrates for transport proteins, and the physiology of the GI tract. Drug metabolizing enzymes are found to be present in the intestine, albeit the content is lower than that found in liver. The presence of pre-absorptive versus post-absorptive intestinal metabolism is presently discussed in experimental sets of data with luminal and systemic administration of the drugs in the vascularly perfused rat small intestine preparation. The effect of the anterior anatomical placement of the intestine and its contribution to metabolism, in relation to that for the liver, has been examined in our laboratory by the perfused intestine-liver preparation. The effect of concentration and flow have been studied and general principles governing drug absorption and metabolism in the intestine and the subsequent effects on the liver have been discussed.

Involvement of the rat gut epithelial and muscular layer, and microflora in chiral inversion and acyl-glucuronidation of R-fenoprofen

In the presence of excised human and rat gut, the pharmacologically inactive R enantiomers of both ibuprofen and fenoprofen (FN) are bioinverted to their anti-inflammatory antipodes. In an attempt to further localize the site of inversion, we incubated R-FN, in oxygenated (O2:CO2, 95:5, v/v) Krebs-Henseleit solution (37 degrees C, pH 7.4) for 3 h in the presence of the intestinal contents, epithelium and muscular layer of upper jejunum and everted jejunum sack of antibiotic treated (500 mg/kg neomycin and erythromycin b.i.d. for 3 days) and control adult female Sprague-Dawley rats. The formation of S-FN and acylglucuronidated FN was examined in the incubation medium using a stereospecific HPLC assay. The metabolic activities are reported per g of wet tissue. The extent of inversion by the everted rat gut was substantial (30.7 +/- 5.1%) but no significant differences between the control and germ-eradicated rats was observed. The epithelial cells were found to be the major site of inversion in the intestinal wall (37.5 +/- 4.7%) with the muscular layer (7.8 +/- 2.1%) and intestinal contents (5.7 +/- 2.2%) contributing only to a small extent to the process. Both enantiomers were substantially acyl-glucuconjugated in the epithelial and muscular layers, and the intestinal content.

Absorption and presystemic metabolism of selegiline hydrochloride at different regions in the gastrointestinal tract in healthy males

PURPOSE

The absorption and disposition of selegiline (SEL) and its metabolites N-desmethylselegiline (DMS), L-methamphetamine (MET), and L-amphetamine (AMP) were assessed in 8 healthy male volunteers at proximal and distal regions of the intestine relative to oral administration (in the stomach) to determine if intestinal site dependence contributed to the erratic oral absorption of selegiline hydrochloride which is manifest as low and variable bioavailability.

METHODS

An open-label, four-way crossover, single dose pharmacokinetic study comparing the bioavailability of 10 mg selegiline hydrochloride administered to healthy young males as a solution by the oral route (in the stomach) and by a nasoenteric tube to the following three sites: duodenum, jejunum and terminal ileum was conducted. Infusions were administered over a 1 minute interval and a two week washout was observed between treatments. Samples were taken over 96 hours and analyzed by LC/MS/MS.

RESULTS

Selegiline exposure was greatest following administration to the stomach (approximately 150% > duodenum or jejunum) and least in the terminal ileum (approximately 33% less than duodenum or jejunum). Duodenal and jejunal sites were equivocal based on selegiline absorption and subsequent metabolism. While both AMP and MET exposure was equivalent at all dosing sites, DMS exposure was less (approximately 18%) at the terminal ileum.

CONCLUSIONS

The oral absorption of selegiline is neither permeability-limited or intestinal site-dependent. Stomach absorption may bypass presystemic metabolism. The reduced DMS exposure at the terminal ileum is consistent with the theorized presystemic formation of DMS via luminal P450 enzymes and the density of these enzymes in the duodenum and jejunum relative to the ileum. AMP and MET metabolites were insensitive to dosing site consistent with their hepatic formation. The true magnitude of these effects would require multiple dosing as single dose pharmacokinetics do not predict the extent of multiple dose selegiline exposure.

First-pass metabolism of midazolam by the human intestine

The in vivo intestinal metabolism of the CYP3A probe midazolam to its principal metabolite, 1'-hydroxymidazolam, was investigated during surgery in 10 liver transplant recipients. After removal of the diseased liver, five subjects received 2 mg midazolam intraduodenally, and the other five received 1 mg midazolam intravenously. Simultaneous arterial and hepatic portal venous blood samples were collected during the anhepatic phase; collection of arterial samples continued after reperfusion of the donor liver. Midazolam, 1'-hydroxymidazolam, and 1'-hydroxymidazolam glucuronide were measured in plasma. A mass balance approach that considered the net change in midazolam (intravenously) or midazolam and 1'-hydroxymidazolam (intraduodenally) concentrations across the splanchnic vascular bed during the anhepatic phase was used to quantitate the intestinal extraction of midazolam after each route of administration. For the intraduodenal group, the mean fraction of the absorbed midazolam dose that was metabolized on transit through the intestinal mucosa was 0.43 +/- 0.18. For the intravenous group, the mean fraction of midazolam extracted from arterial blood and metabolized during each passage through the splanchnic vascular bed was 0.08 +/- 0.11. Although there was significant intersubject variability, the mean intravenous and intraduodenal extraction fractions were statistically different (p = 0.009). Collectively, these results show that the small intestine contributes significantly to the first-pass oxidative metabolism of midazolam catalyzed by mucosal CYP3A4 and suggest that significant first-pass metabolism may be a general phenomenon for all high-turnover CYP3A4 substrates.

An in vitro method for predicting in vivo oral bioavailability of novel immunosuppressive drugs

OBJECTIVE

To evaluate an in vitro method for predicting oral availability of novel immunosuppressive drugs, cyclosporine A (CsA) and rapamycin (RAPA).

METHODS

In this study, we report the development and characterization of an in vitro method to study the influence of vehicle composition on cyclosporine A (CsA) and rapamycin (RAPA) drug efflux across 12 days postconfluent, absorptive human Caco-2 intestinal epithelial cell monolayers. The apical-to-basal (Jab) and the basal-to-apical (Jba) fluxes of 0.5 muCi 3H-CsA or 0.05 muCi 14C-RAPA solubilized in a 10 mg/L final drug concentration in vehicle were measured.

RESULTS

The Jab CsA flux was found to be dose dependent, temperature sensitive, and highly polarized (Jab > Jba). For CsA the vehicles were Neoral, Sandimmune, 95% (v/v) ethanol/fetal bovine serum (ethanol/FBS); and for RAPA these were polyethylene glycol/dimethylacetamide (PEG/DMA), polysorbate/Phosal PEG, ethanol/FBS. When Neoral-CsA was tested, the Jab flux of 3H-CsA was the highest and increased almost linearly even after an incubate time of 240 min. The Jab flux of 3H-CsA when Sandimmune-CsA or ethanol/FBS-CsA were used as vehicle was lower and reached a maximal rate by 120 min. In contrast the Jab flux of 14C-RAPA using either PEG/DMA-RAPA or ethanol/FBS-RAPA as vehicle was highest and reached a maximal rate by 120 min, in contrast to the polysorbate/Phosal PEG-RAPA vehicle, which was significantly lower.

CONCLUSION

These data are consistent with the pharmacokinetics of these ISD reported in vivo in human patients or in rabbits, using the same vehicles in the oral formulation. As an integral part of drug development, the data presented that an in vitro system as described may be useful in predicting the effect of drug vehicle on absorption in vivo.

First-pass metabolism of diltiazem in anesthetized rabbits: role of extrahepatic organs

PURPOSE

The aim of this study was to assess in vivo which organs contribute to the first-pass metabolism of diltiazem.

METHODS

Anaesthetized rabbits received diltiazem into the thoracic aorta (TA) ( 1mg/kg), jugular vein (JV) (2 mg/kg), portal vein (PV) (4 mg/kg) or small intestine (SI) (5 mg/kg). Serial blood samples were withdrawn from the abnormal aorta to assay diltiazem, N-demethyl-diltiazem (MA) and deacetyldiltiazem (M1).

RESULTS

The area under diltiazem plasma concentration curve/time (AUC0-infinity) normalized by the dose was AUCTA approximately equal to AUCJV > AUCPV > AUCSI: Intestinal and hepatic diltiazem availability was 43 and 33%, respectively. The systemic availability of oral diltiazem was 12%. Diltiazem given into the SI and PV generated primarily MA, and injected into the JV and TA produced mainly M1.

CONCLUSIONS

In rabbits, the intestine and the liver contribute to the first-pass metabolism of diltiazem, and the amount and species of metabolites generated depend upon the route of administration of diltiazem.

Decreased intestinal CYP3A in celiac disease: reversal after successful gluten-free diet: a potential source of interindividual variability in first-pass drug metabolism

BACKGROUND

Cytochrome P450 (CYP) 3A is constitutively expressed in human intestinal villi and may account for significant "first-pass" prehepatic metabolism of a number of drugs in the intestine. Celiac disease results in small intestinal atrophy. We hypothesized that this would result in a loss of CYP3A.

METHODS

Formalin-fixed jejunal biopsy specimens taken from nine patients with celiac disease at variable times before and after treatment with a gluten-free diet were immunoperoxidase stained after incubation with anti-CYP3A4 rabbit antisera (1:2000 dilution). The amount of immunoreactive CYP3A was determined by two observers who were blinded to the treatment states of the patients. Staining intensity was graded on a numerical scale from 1 to 4+ on the basis of intensity of staining in individual enterocytes, as well as the total number of enterocytes stained.

RESULTS

Slides of biopsy specimens from all nine untreated patients with celiac disease were graded 1. Treatment with a gluten-free diet was associated with a significant increase in CYP3A immunoreactive protein in small bowel biopsy specimens (p < 0.05, Wilcoxon signed-rank test).

CONCLUSIONS

We conclude that patients with celiac disease have low intestinal CYP3A immunoreactivity and that treatment with a gluten-free diet is associated with an increase in intestinal CYP3A immunoreactive protein. Our findings suggest that intestinal disease and variability in intestinal CYP3A activity might be an unexamined variable that may contribute to interindividual variability in drug disposition.

Absorption and presystemic metabolism of nefazodone administered at different regions in the gastrointestinal tract of humans

PURPOSE

The absorption and disposition of nefazodone (NEF) and its metabolites hydroxynefazodone (HO-NEF), m-chlorophenylpiperazine (mCPP) and triazole dione (dione) were assessed in 10 healthy subjects following infusion of NEF solution into the proximal and distal regions of the intestine vs administration of NEF solution orally by mouth.

METHODS

NEF HCl (400 mg) was infused over 5 hours into the proximal or distal intestine through a nasogastric tube, or orally ingested in 10 divided doses over 4.5 hours. The three treatments in the three-period crossover design were separated by one week.

RESULTS

The bioavailability of NEF, based on AUC(INF), from proximal and distal regions relative to that from oral administration was 97% and 106%, respectively. NEF was absorbed equally well from all three treatments with median Tmax of 5.0 hours which coincided with the duration of infusion. Mean Cmax of NEF was not different between proximal and oral administrations, however, mean Cmax after distal instillation was 40% lower than that after oral administration. Exposure to HO-NEF, mCPP and dione, following proximal instillation was also comparable to that after oral administration. AUC(INF) of HO-NEF and dione was significantly lower after distal instillation compared to that after oral administration but AUC(INF) of mCPP was not. Cmax of all metabolites was significantly lower after distal administration in comparison to oral treatment. Terminal half-life for NEF, HO-NEF and mCPP after distal administration was longer than the other two treatments.

CONCLUSIONS

NEF is absorbed throughout the length of the gastro-intestinal tract which supports the development of an extended-release formulation of NEF. The exposure to the metabolites (relative to NEF) was lower from the distal intestinal site compared to the proximal and oral site which may be explained by a reduced first pass of NEF by the cytochrome P450 3A4 in the distal intestine.

Metabolism of diltiazem in hepatic and extrahepatic tissues of rabbits: in vitro studies

Diltiazem (DTZ) is a calcium channel blocker widely used in the treatment of angina and hypertension. DTZ undergoes extensive metabolism yielding several metabolites, some of which are active like N-desmethyldiltiazem (MA), desacetyldiltiazem (M1) and N-desmethyl,desacetyldiltiazem (M2). Due to the nature of its biotransformation, several organs should have the ability to metabolize DTZ, however it is still assumed that the liver is the only organ implicated in its elimination. In this study, the fate of DTZ, MA and M1 was assessed in several organs that could contribute to their biotransformation. To this purpose, DTZ (48.2 microM) was incubated in the 10,000 x g supernatant of homogenates of rabbit tissues for 60 min at 37 degrees C. Multiple samples were withdrawn, and DTZ and its metabolites were assayed by HPLC. The elimination rate constant of DTZ in 10,000 x g supernatants varied between the organs: liver 334 +/- 45, proximal small intestine 69 +/- 11, distal small intestine 25 +/- 3, lungs 15 +/- 6 and kidneys 8 +/- 6 (10(-4) min-1). The metabolism of DTZ in the liver generated large amounts of MA but no M1, and in the small intestine, modest amounts of both metabolites. When MA (50.0 microM) or M1 (53.7 microM) were incubated in liver homogenates, the estimated elimination rate constant were 166 +/- 23 and 468 +/- 53 (10(-4) min-1), respectively. The rate of degradation of the metabolites in the small intestine was much slower.(ABSTRACT TRUNCATED AT 250 WORDS)

Sumatriptan absorption from different regions of the human gastrointestinal tract

Sumatriptan exhibits low oral bioavailability partly due to presystemic metabolism, which may vary with regional differences in metabolic activity throughout the gastrointestinal tract. This study evaluated sumatriptan absorption in humans after administration orally and by oroenteric tube into the jejunum and cecum. Because the site of cecal administration varied, pharmacokinetic parameters for sumatriptan and its major metabolite were compared statistically only after oral and jejunal administration. One-half of the oral dose was recovered in the urine as parent (3%) and metabolite (46%). Sumatriptan was absorbed throughout the gastrointestinal tract; absorption was similar after oral and jejunal administration, and less after cecal administration. The metabolite AUC and the AUC ratio (metabolite/parent) were significantly lower after jejunal compared to oral administration; the AUC ratio was two-fold lower after cecal administration. Results suggest that presystemic metabolism of sumatriptan varies throughout the gastrointestinal tract and/or regional differences exist in the absorption of metabolite formed within the gastrointestinal tract.

The metabolism of drugs by the gut flora

Gut flora and gut contents can be considered as a system with huge metabolic capacity, qualitatively and quantitatively different from the body cells and organs. That system changes along with life and nutrition, but despite broad investigation has not yet been defined satisfactorily. In many cases inter individual and intra individual differences in drug metabolism could be linked to variations in the gut flora metabolism. Gut flora metabolism of drugs and other xenobiotic metabolites excreted in bile is the key phase responsible for enterohepatic circulation. In the last decade there has been more and more evidence for the crucial role of the gut flora cysteine conjugate beta-lyase in the metabolism of cysteine conjugates. A new pathway for paracetamol cysteine conjugate metabolism has been directly linked with gut flora activity, as demonstrated in our studies. Nowadays, it is quite clear that gut flora metabolism must be considered an integral part of drug metabolism and toxicity studies.

Concentrations of morphine, morphine-6-glucuronide and morphine-3-glucuronide in serum and cerebrospinal fluid following morphine administration to patients with morphine-resistant pain

Recent studies have suggested that morphine-3-glucuronide (M3G) may antagonize the analgesic effects of morphine and morphine-6-glucuronide (M6G). To investigate this hypothesis, steady-state concentrations of morphine, M6G and M3G in serum and cerebrospinal fluid (CSF) were measured in 11 patients receiving chronic morphine therapy (9 orally and 2 subcutaneously) for treatment of cancer-related pain. All patients appeared to have morphine-resistant pain and had elected to proceed to intrathecal bupivacaine or percutaneous cordotomy. Morphine, M6G and M3G concentrations were measured by high-performance liquid chromatography. The concentrations (median and range) for morphine, M6G and M3G in serum were 193 (14-1086) nmol/l, 847 (210-4113) nmol/l and 4553 (1324-24035) nmol/l, respectively, while in CSF concentrations of morphine, M6G and M3G were 200 (21-1461) nmol/l, 115 (30-427) nmol/l and 719 (249-3252) nmol/l, respectively. Median molar ratios of M6G/morphine and M3G/morphine in serum were 3.79 and 22.1, respectively, while in CSF the same ratios were 0.42 and 2.39, respectively. Median molar ratios of M3G/M6G in serum and CSF were 5.84 and 6.61, respectively. The median molar ratios for CSF/serum distribution of morphine, M6G and M3G were 1.23, 0.12 and 0.14, respectively. Thus, despite their relatively poor ability to penetrate into the CSF, the high serum concentrations of M6G and M3G resulted in substantial concentrations of these metabolites in the CSF. Nevertheless, M3G/M6G ratios in our morphine-resistant patients were similar to published values in patients with well-controlled pain, suggesting that the hypothesis that M3G plays a major role in morphine-resistance is not correct.

The use of liquid chromatography/thermospray mass spectrometry with on-line ultraviolet diode array and radiochemical detection: characterization of the putative metabolites of U-78875 in female rat faeces

The metabolites of an anxiolytic drug candidate U-78875 [3-(5-cyclopropyl-1,2,4-oxadiazol-3-yl)-5-(1-methylethyl)- imidazo[1,5-alpha]quinoxalin-4(5H)-one; I] were investigated in female rat faecal extracts following a single oral dose of (14C)I. Initial metabolite profiling was performed by high-performance liquid chromatography incorporating homogeneous (i.e. liquid scintillant added post-column) radiochemical detection (radio-HPLC). This indicated the presence of parent drug and one minor metabolite. Because liquid scintillant is incompatible with thermospray interfaces, subsequent analysis by thermospray/HPLC/MS (TSP/LC/MS) incorporated radiochemical detection in heterogeneous (i.e. solid scintillant) mode and ultraviolet (UV) diode array detection. This revealed that the peak thought previously to be parent drug contained two components: a metabolite (major) and parent drug (minor). The UV spectrum and TSP/LC/MS/MS daughter ion analysis led to the proposition of a bisamide structure for the major metabolite. Chemical synthesis was used to confirm this structure. TSP/LC/MS indicated that the molecular weight of the minor metabolite was 16 u higher than the bisamide, suggesting an oxidized analogue. Attempts to obtain a daughter ion spectrum on this minor metabolite proved unsuccessful. On-line radiochemical and UV diode array detection greatly facilitates the TSP/LC/MS characterization of metabolites from studies using radiolabelled drugs.

Dietary lipids induce phase 2 enzymes in rat small intestine

We examined the role of dietary lipids in determining the activities of glutathione S-transferase (GST) and UDPglucuronosyl-transferase (UGT) in rat small intestine. Male Wistar rats were fed a fat-free (FF) diet or isocaloric control diet containing 5% corn oil (CO) or 5% fish oil (FO) for 3 weeks. The activities of these enzymes were about 2-fold higher in rats fed the FO diet vs. the FF diet. Intermediate levels of enzyme activity were found in rats fed the CO diet. Diet-induced differences in enzyme levels were shown by immunoblotting. The highest levels of glutathione S-transferase and UDPglucuronosyltransferase were detected in rats fed the FO diet. The lowest levels of these enzymes were found in rats fed the FF diet. Intermediate levels of enzyme were detected in rats fed the CO diet. Thus, diet-induced differences in enzyme activities were paralleled by changes in enzyme levels. Fatty acid analysis of mucosal lipids showed that the FF and FO diets were associated with decreased levels of linoleic and arachidonic acids as compared with the CO diet.

Individual variation in first-pass metabolism

Individual variation in pharmacokinetics has long been recognised. This variability is extremely pronounced in drugs that undergo extensive first-pass metabolism. Drug concentrations obtained from individuals given the same dose could range several-fold, even in young healthy volunteers. In addition to the liver, which is the major organ for drug and xenobiotic metabolism, the gut and the lung can contribute significantly to variability in first-pass metabolism. Unfortunately, the contributions of the latter 2 organs are difficult to quantify because conventional in vivo methods for quantifying first-pass metabolism are not sufficiently specific. Drugs that are mainly eliminated by phase II metabolism (e.g. estrogens and progestogens, morphine, etc.) undergo significant first-pass gut metabolism. This is because the gut is rich in conjugating enzymes. The role of the lung in first-pass metabolism is not clear, although it is quite avid in binding basic drugs such as lidocaine (lignocaine), propranolol, etc. Factors such as age, gender, disease states, enzyme induction and inhibition, genetic polymorphism and food effects have been implicated in causing variability in pharmacokinetics of drugs that undergo extensive first-pass metabolism. Of various factors considered, age and gender make the least evident contributions, whereas genetic polymorphism, enzymatic changes due to induction or inhibition, and the effects of food are major contributors to the variability in first-pass metabolism. These factors can easily cause several-fold variations. Polymorphic disposition of imipramine and propafenone, an increase in verapamil first-pass metabolism by rifampicin (rifampin), and the effects of food on propranolol, metoprolol and propafenone, are typical examples. Unfortunately, the contributions of these factors towards variability are unpredictable and tend to be drug-dependent. A change in steady-state clearance of a drug can sometimes be exacerbated when first-pass metabolism and systemic clearance of a drug are simultaneously altered. Therefore, an understanding of the source of variability is the key to the optimisation of therapy.

Presystemic extraction: mechanisms and consequences

Many drugs have incomplete systemic availability after oral dosage. This can be attributed to incomplete absorption from the gastrointestinal tract, or to presystemic extraction, in which a fraction of an orally administered dose is biotransformed before reaching the systemic circulation. Presystemic extraction can occur either via biotransformation by gastrointestinal mucosa or enteric flora, or via metabolism during the "first-pass" through the liver. For drugs with low oral bioavailability due to high presystemic extraction, impaired clearance leads to increased peak plasma levels and greater area under the concentration-time curve, but minimal change in elimination half-life.

The disposition of nifurtimox in the rat isolated perfused liver: effect of dose size

The disposition of nifurtimox was studied in the rat isolated perfused liver using a recirculating system. The drug was administered as a bolus (5.0, 15.0 or 30.0 micrograms mL-1), and its disappearance was monitored by analysing perfusate samples. In all experiments perfusate disappearance was monoexponential, and no significant difference was found between the three doses for the elimination constant (0.016, 0.011 and 0.012 min-1, respectively), half-life (46.6, 65.8 and 66.8 min, respectively), extraction rate (0.128, 0.091 and 0.099, respectively) and distribution volume (41.1, 47.3 and 30.7 mL g-1, respectively). At 30 micrograms mL-1 the hepatic clearance was lower than the other concentrations of nifurtimox (0.66, 0.51 and 0.34 mL min-1 g-1, respectively). Relatively little parent drug was recovered from the liver at the end of the perfusions. In summary, nifurtimox is cleared slowly from the rat isolated perfused liver, is poorly extracted by hepatocyte cells and is completely metabolized from 2 to 4 h after perfusion.