Excretion and biotransformation of the enanthate ester of fluphenazine- 14 C by the dog

Severe rhinorrhea and respiratory distress in a neonate exposed to fluphenazine hydrochloride prenatally

OBJECTIVE

To report a case of respiratory distress with severe rhinorrhea in a newborn exposed prenatally to fluphenazine hydrochloride.

CASE SUMMARY

The safety of phenothiazines during pregnancy and the effect on the fetus and newborn are not well known. We describe a newborn who had severe rhinorrhea, vomiting, and respiratory distress after being exposed in utero to fluphenazine hydrochloride. Sepsis, choanal atresia, and congenital syphilis were excluded as causative factors for rhinorrhea. The rhinorrhea and upper airway obstruction responded to treatment with pseudoephedrine.

CONCLUSIONS

Severe rhinorrhea, vomiting, and respiratory distress that occurred in this infant have not been reported previously following prenatal fluphenazine hydrochloride exposure. Awareness of this problem would be helpful to clinicians and should be considered in the differential diagnosis of rhinorrhea in newborns.

Biosynthesis and characterization of glucuronide metabolites of fluphenazine: 7-hydroxyfluphenazine glucuronide and fluphenazine glucuronide

1. To expedite direct studies on phase II metabolites of fluphenazine, pure fluphenazine or 7-hydroxyfluphenazine were incubated with a rabbit hepatic microsomal immobilized enzyme system. After purification and recrystallization a high yield (60%) of 7-hydroxy-beta-D-O-glucuronyl-fluphenazine was obtained. 2. The structure of this glucuronide was proven unambiguously by mass spectrometry (fast atom bombardment, daughter ion analysis, electron impact, chemical ionization) and 1H-n.m.r. and 13C-n.m.r. spectroscopy. The phenolic ether glucuronide was the sole product of the reaction. 3. There was no evidence of conjugation at the primary alcohol group of the side-chain of fluphenazine, or of the formation of quaternary ammonium-linked glucuronides with either of tertiary aliphatic nitrogen atoms of the side-chain. 4. Incubation of fluphenazine with the immobilized enzyme system gave a poor yield (less than 1%) of the aliphatic ether glucuronide as reaction product, consistent with a low susceptibility of the side-chain primary alcohol function of fluphenazine to glucuronidation.

Enzymatic hydrolysis of haloperidol decanoate and its inhibition by proteins

When [14C]haloperidol decanoate, a long-acting neuroleptic and an ester of haloperidol and decanoic acid, was incubated in human whole blood and plasma and in rat plasma and homogenates of rat brain, lung, liver, kidney, pancreas and muscle, no hydrolysis of the ester was seen. Although the decanoate was hydrolyzed by partially purified carboxylesterase, addition of rat plasma or liver homogenate to the enzymic reaction mixture resulted in marked inhibition of hydrolysis, whereas addition of the defatted residues of plasma or liver produced only partial inhibition. The enzymic hydrolysis was inhibited also by beta-lipoprotein and albumin, depending on their concentrations. The assumption that interaction between haloperidol decanoate and protein resulted in inhibition of the hydrolytic reaction mediated by the enzyme was validated by kinetic models and experimental data. The kinetics were apparently competitive. Based on the kinetic analysis, the interaction between the decanoate and albumin or beta-lipoprotein was investigated by measuring their equilibrium constants and extent of protein binding. Haloperidol decanoate appeared to interact with several proteins; this was exemplified by other measures of protein binding, an increasing effect of proteins on the solubility, and the partition ratio of the ester. The interaction between haloperidol decanoate and proteins caused marked stabilization of this ester against enzymatic hydrolysis and, thereby, influenced its metabolism.

Clinical pharmacokinetics of the depot antipsychotics

The clinical pharmacokinetics of the 4 depot antipsychotics for which plasma level studies are available (i.e. fluphenazine enanthate and decanoate, haloperidol decanoate, clopenthixol decanoate and flupenthixol decanoate) are reviewed. The proper study of these agents has been handicapped until recently by the necessity of accurately measuring subnanomolar concentrations in plasma. Their kinetic properties, the relationship of plasma concentrations to clinical effects, and conversion from oral to injectable therapy are discussed. The depot antipsychotics are synthesised by esterification of the active drug to a long chain fatty acid and the resultant compound is then dissolved in a vegetable oil. The absorption rate constant is slower than the elimination rate constant and therefore, the depot antipsychotics exhibit 'flip-flop' kinetics where the time to steady-state is a function of the absorption rate, and the concentration at steady-state is a function of the elimination rate. Fluphenazine is available as both an enanthate and decanoate ester (both dissolved in sesame oil), although the decanoate is more commonly used clinically. The enanthate produces peak plasma concentrations on days 2 to 3 and declines with an apparent elimination half-life (i.e. the half-time of the apparent first-order decline of plasma concentrations) of 3.5 to 4 days after a single injection. The decanoate produces an early high peak which occurs during the first day and then declines with an apparent half-life ranging from 6.8 to 9.6 days following a single injection. After multiple injections of fluphenazine decanoate, however, the mean apparent half-life increases to 14.3 days, and the time to reach steady-state is 4 to 6 weeks. Withdrawal studies with fluphenazine decanoate suggest that relapsing patients have a more rapid plasma concentration decline than non-relapsing patients, and that the plasma concentrations do not decline smoothly but may exhibit 'lumps' due to residual release from previous injection sites or multicompartment redistribution. Cigarette smoking has been found to be associated with a 2.33-fold increase in the clearance of fluphenazine decanoate. In 3 different studies, fluphenazine has been proposed to have a therapeutic range from less than 0.15 to 0.5 ng/ml with an upper therapeutic range of 4.0 ng/ml. Plasma concentrations following the decanoate injection are generally lower than, but clinically equivalent to, those attained with the oral form of the drug. Haloperidol decanoate plasma concentrations peak on the seventh day following injection although, in some patients, this peak may occur on the first day.(ABSTRACT TRUNCATED AT 400 WORDS)

Animal model for investigation of fluphenazine kinetics after administration of long-acting esters

A model was developed for studying fluphenazine availability and disposition. Rats were given doses of radioactively labelled esters of fluphenazine by intramuscular injection. Radioactivity excreted in urine, faeces, and expired air was assessed for fluphenazine esters, fluphenazine, and CO2 content. Levels of fluphenazine and its esters were measured in plasma, brain, and muscle (injected and non-injected samples). The data mimicked those obtained in other studies involving the same material given to human subjects, and posed new questions concerning the factors controlling fluphenazine availability when given as 'long-acting' intramuscular injections.

Kinetics of fluphenazine after fluphenazine dihydrochloride, enanthate and decanoate administration to man

1 Fluphenazine (1,2-ethanol 14C) was administered to seven human subjects as the dihydrochloride and as the enanthate and decanoate esters. 2 The subjects had previously been treated with fluphenazine injections for at least 6 months. 3 Fluphenazine was separated from its radioactive metabolites by selective solvent extraction. Plasma concentrations were measured for up to 21 days after dosing. 4 The preparations showed differences in peak concentrations, times of the peaks and half-times of the elimination phase. The longest half-times occurred with the decanoate and the shortest with the dihydrochloride. 5 It is postulated that the differences in kinetics relate principally to the release of the compound from the site of injection. 6 There was no evidence for presence of the esters in plasma, urine or faeces.

Methods for study of fluphenazine kinetics in man

Fluphenazine and its principal metabolites, fluphenazine sulphoxide, and 7-hydroxyfluphenazine were identified and quantified in human plasma, urine and faeces following intramuscular and oral administration of 14C-fluphenazine dihydrochloride. The presence of a conjugate fraction was also noted. Unmetabolized fluphenazine was selectively extracted into n-heptane. The metabolites were separated by solvent extraction into toluene. Conjugates were hydrolysed back to fluphenazine, fluphenazne sulphoxide and 7-hydroxyfluphenazine. Fluphenazine and fluphenazine conjugates were also measured in the urine of patients receiving long term non-radioactive fluphenazine decanoate therapy. The urinary excretion rate of the conjugate fraction was systematically related to the plasma concentration, regardless of urine flow rate or pH, providing a convenient method for the assessment of fluphenazine kinetics by urinary excretion studies not involving administration of labelled drug.

Anodic coulometric detection with a glassy carbon electrode in combination with reversed-phase high-performance liquid chromatography. Determination of blood levels of perphenazine and fluphenazine

A detector for liquid chromatography, based on anodic electrochemical oxidation at a glassy carbon electrode, is used in combination with reversed-phase liquid chromatography for the determination of the long-acting tricyclic psychotropic drugs fluphenazine and perphenazine in blood. Completely porous microparticulate silica material, modified so as to give a methyl silica, was used as the stationary phase and buffered mixtures of methanol and water as the mobile phase. The low detection limit and the selectivity of the coulometric detector made possible the determination of concentrations of 1-20 ppb of the compounds of interest. An extraction procedure was in order to obtain sufficient selectivity. Data for the precision, detection limit and yield of the extraction procedure are given. A number of serum levels of perphenazine after oral administration and of fluphenazine after i.m. doses of fluphenazine decanoate are stated.