Metabolism of triamcinolone acetonide-21-phosphate in dogs, monkeys, and rats

Anaphylaxis Induced by Intramuscular Betamethasone Disodium Phosphate: Reflections on a Clinical Case

Glucocorticoids could be responsible for allergic symptoms correlated to an Ig-E mediated hypersensitivity mechanism. We describe the case of an anaphylactic reaction in a professional nurse, occurring after an intramuscular administration of Betamethasone. After performing skin prick tests, intramuscular tests and patch tests we concluded that the patient had Ig-E mediated sensitization. She was prescribed oral Prednisone and Deflazacort and shows good tolerance of these drugs. This demonstrates that in these patients it is possible to administrate glucocorticoids without the changes in the sites indicated by Wilkinson. Nevertheless, our patient showed a negative allergy test for Dexamethasone disodium phosphate, and in those patients sensitized to fluorinated glucocorticoids, tolerance to other glucocorticoids is not so easily predictable as in patients with hypersensitivity to first generation steroids or in corticosteroid contact dermatitis, according to the four patterns of cross-reactivity proposed by Coopman and Dooms-Goossens.

Detection and characterization of triamcinolone acetonide metabolites in human urine by liquid chromatography/tandem mass spectrometry after intramuscular administration

RATIONALE

Glucocorticosteroids are prohibited in sports when used by systemic administrations (e.g. intramuscular, IM), whereas they are allowed using other ways of administration. Strategies to discriminate between administrations routes have to be developed by doping control laboratories. For this reason, the metabolism of triamcinolone acetonide (TA), one of the most used glucocorticosteroids, was studied using liquid chromatography coupled to tandem mass spectrometry (LC/MS/MS).

METHODS

Urine samples obtained after IM administration of TA were analyzed using two sample treatments: (a) hydrolysis with β-glucuronidase enzymes and liquid-liquid extraction under alkaline conditions, and (b) liquid-liquid extraction under acidic conditions. The extracts were analyzed by LC/MS/MS.

RESULTS

TA, commercially available metabolites (6β-hydroxytriamcinolone acetonide, 6β-OH-TA, and triamcinolone), and their C20-reduced derivatives showed characteristic fragmentation behavior. Besides common product ions and neutral losses for corticosteroids containing fluorine, additional characteristic neutral losses (58 Da, loss of acetone; 44 Da, loss of acetaldehyde) were observed in positive electrospray ionization. Based on that behavior, two complementary approaches were applied to detect TA metabolites: (a) open detection by precursor ion and neutral loss scan methods and (b) targeted detection by selected reaction monitoring methods (SRM) containing theoretical ion transitions of the potential metabolites. Two main compounds, TA and 6β-OH-TA, and nine minor potential metabolites, were detected by open screening methods. Using SRM, two additional metabolites were detected. Some of the metabolites were characterized using reference standards and, for the rest of metabolites, feasible structures were proposed based on mass spectrometric data.

CONCLUSIONS

Metabolites resulting from hydroxylation in C-6, oxidation of the 11-hydroxyl group, reduction of the Δ(4) double bond and oxidation of the side chain were detected. Some of them have not been previously described. Excretion profiles of the detected metabolites after IM administration are presented.

Positive doping results caused by the single-dose local injection of triamcinolone acetonide

Triamcinolone acetonide (TA) is classified as an S9 glucocorticoid in the 2014 Prohibited List published by the World Anti-Doping Agency, which caused it to be prohibited in-competition when administered orally, intravenously, intramuscularly or rectally. The Minimum Required Performance Level (MRPL) for the detection and identification of glucocorticoids is 30 ng/mL. Other common local injection routes, such as intraarticular, intratendinous, or intrabursal injection, are not prohibited. The purpose of this study was to analyze the TA and triamcinolone (T) concentrations in urine after a single injection of TA in patients to determine if it would produce a positive result. This study was performed on 40 patients with sports injuries or joint pains. TA was administered locally (doses varied from 12 to 80 mg). Samples were extracted using a solid-phase extraction column, followed by hydrolysis and liquid extraction using diethyl ether. The elution solvents were collected and dried. The dried residue was reconstituted and assayed by performing liquid chromatography-tandem mass spectrometry (LC-MS/MS) in positive ionization mode using electrospray ionization and multiple-reaction monitoring as the acquisition mode. The results demonstrated that the concentrations of both TA and T in urine exceeded the MRPL (30 ng/mL) after a single local injection. We obtained positive results for TA in 25 patients, and a positive result for T in one patient. Furthermore, the metabolic situation of TA, a long-acting glucocorticoid, was not an exact linear model. The highest concentrations of TA and T appeared 1-4h after injection. This information could be useful for limiting the misuse of TA by athletes. We suggest that athletes be aware when using TA injections during a competition period and obtain approval for therapeutic use exemption prior to using TA.

METABOLISM OF MOMETASONE FUROATE AND BIOLOGICAL ACTIVITY OF THE METABOLITES

To better evaluate the pharmacokinetic and pharmacodynamic properties of the new inhaled glucocorticoid mometasone furoate (MF), the metabolism of MF was evaluated in rat and human tissues and in rat after i.v. administration. Metabolic studies with 3H-MF in human and rat plasma and S9 fractions of human and rat lung showed relatively high stability and a degradation pattern similar to that seen in buffer systems. MF was efficiently metabolized into at least five metabolites in S9 fractions of both rat and human liver. There were, however, quantitative differences in the metabolites between the two species. The apparent half-life of MF in the S9 fraction of human liver was found to be 3 times greater compared with that in rat. MET1, the most polar metabolite, was the major metabolite in rat liver fractions, whereas both MET1 and MET2 were formed to an equal extent in human liver. Metabolism and distribution studies in rats after intravenous and intratracheal administration of [1,2-(3)H]MF revealed that most of the radioactivity (approximately 90%) was present in the stomach, intestines, and intestinal contents, suggesting biliary excretion of MF and its metabolites. Radiochromatography showed that most radioactivity was associated with MET1, MET2, and MET 3. Fractionation of the high-performance liquid chromatography eluate (MET1-5) revealed that only MF [relative binding affinity (RBA) 2900] and MET2 (RBA 700) had appreciable glucocorticoid receptor binding affinity. These results suggest that MF undergoes distinct extrahepatic metabolism but generates active metabolites that might be in part responsible for the systemic side effects of MF.

Microdialysis of triamcinolone acetonide in rat muscle

The objective of this study was to compare plasma and muscle concentrations of triamcinolone acetonide (TA) in the rat by microdialysis. Microdialysis experiments were carried out at steady state in rats after an initial I.V. bolus 50 mg/kg of the phosphate ester of TA (TAP) followed by 23 mg/kg/h infusion. In vivo recovery was calculated by retrodialysis. The concentration determined at steady state in microdialysate, corrected for recovery, was 2.73 +/- 0.42 microg/mL compared to 21.9 +/- 2.3 microg/mL in plasma. The pharmacokinetics of TA in plasma was described by an open two-compartment model with a terminal half-life of 2.7 h. The clearance of TA in rats determined by compartmental analysis was 0.94 L/h/kg. The measured microdialysate levels of TA in muscle, corrected for recovery, were comparable to the predicted free drug levels in the peripheral compartment. Protein binding in rat plasma, measured by ultrafiltration, was 90.1%. The microdialysis in vivo recovery in muscle was similar to the in vitro recovery under stirred conditions. The results show the applicability of microdialysis to measure free tissue concentrations of TA in rats.

Effect of structural alterations on the biotransformation rate of glucocorticosteroids in rat and human liver

The effect of structural alterations on the biotransformation rate of glucocorticosteroids (GCS) by rat- and human-liver 9000 g supernatant fraction was studied. Insertion of a 16 alpha-hydroxy group in the prednisolone molecule (16 alpha-hydroxyprednisolone) was found to decrease the rate of biotransformation. Substitution of the 16 alpha,17 alpha-hydroxy groups with a symmetric acetal (in, for example, desonide) or especially a non-symmetric acetal (in, for example, budesonide), enhanced the biotransformation rate several-fold, particularly in human liver. Differences in the rates of metabolism in rat and human liver were observed. Hydrogenation of the 1,2-double bond in prednisolone and budesonide (hydrocortisone and 1,2-dihydrobudesonide) enhanced the biotransformation rate nine-fold in rat liver but only two-fold in human liver. Fluorination of the steroid nucleus in 6 alpha- and 9 alpha-positions enhanced the biotransformation rate several-fold in human liver, but in rat liver fluorination marginally decreased the rate of biotransformation. These in vitro results correlate well with available data on the first-pass liver metabolism of the studied GCS. This indicates that in vitro data can be useful in predicting oral bioavailability of GCS.

Oral absorption of 21-corticosteroid esters: a function of aqueous stability and intestinal enzyme activity and distribution

The intestinal absorption of hydrocortisone and prednisolone are compared with three water-soluble derivatives (succinate, phosphate, and lysinate) in experiments at two levels of biological system complexity. Rates of absorption are compared by measuring permeabilities from rat intestinal perfusions of drugs and derivatives in solution. Extents of absorption are compared over a 10-fold dose range of parent steroid and with the steroid derivatives by measuring plasma levels from solid oral dosage in dogs. While the parent steroids are well absorbed over the entire length of the intestinal tract, variability in plasma levels is observed at higher doses. Limited solubility and resultant dissolution rate variability are likely to be playing a role in the early erratic blood level profiles found at higher doses. While the soluble prodrugs have a dissolution rate advantage which results in a greater concentration gradient, their absorption is limited by their aqueous luminal stability, their polarity and resultant passive membrane permeability, and the distribution and activity of enzyme reconversion sites in the intestinal tract. The unstable lysinate ester, targeted for aminopeptidase, has an absorption profile and permeability similar to that of the parent steroid. The absorption of the moderately stable succinate ester is limited by its polarity and the activity of intestinal esterases. The stable phosphate derivative is well absorbed in the upper intestine, where high levels of alkaline phosphatase exist, while the prodrug polarity and drop-off of enzyme activity limit its absorption from the lower gastrointestinal (GI) tract.

The biotransformation and urinary excretion of dexamethasone in equine male castrates

The pro-drugs of dexamethasone, a potent glucocorticoid, are frequently used as anti-inflammatory steroids in equine veterinary practice. In the present study the biotransformation and urinary excretion of tritium labelled dexamethasone were investigated in cross-bred castrated male horses after therapeutic doses. Between 40-50% of the administered radioactivity was excreted in the urine within 24 h; a further 10% being excreted over the next 3 days. The urinary radioactivity was largely excreted in the unconjugated steroid fraction. In the first 24 h urine sample, 26-36% of the total dose was recovered in the unconjugated fraction, 8-13% in the conjugated fraction and about 5% was unextractable from the urine. The metabolites identified by microchemical transformations and thin-layer chromatography were unchanged dexamethasone, 17-oxodexamethasone, 11-dehydrodexamethasone, 20-dihydrodexamethasone, 6-hydroxydexamethasone and 6-hydroxy-17-oxodexamethasone together accounting for approx 60% of the urinary activity. About 25% of the urinary radioactivity associated with polar metabolites still remains unidentified.

Identification and quantification of 6 beta-hydroxydexamethasone as a major urinary metabolite of dexamethasone in man

Identification of 6 beta-hydroxydexamethasone as a major urinary metabolite of dexamethasone in man has been accomplished by nuclear magnetic resonance spectroscopy and gas chromatography-mass spectrometry. Mass fragmentographic measurements revealed that more than 30% of the intravenously or orally administered dexamethasone dose was excreted in the 24-h urine as 6 beta-hydroxydexamethasone, while only a small fraction of the dose was excreted as unchanged dexamethasone and its glucuronic acid conjugate.

Pharmacokinetics of triamcinolone acetonide and its phosphate ester

Triamcinolone acetonide in the form of its phosphate ester was given intravenously in two different doses (10 mg/kg and 80 mg). Plasma levels of the ester and triamcinolone acetonide were measured and pharmacokinetic parameters were calculated. The pharmacokinetics both of the phosphate and the free alcohol were dose-dependent. No unchanged ester was found in the urine, indicating complete conversion of the pro-drug. Triamcinolone was not a major metabolite of triamcinolone acetonide in humans. Renal clearance was low and independent of the dose. Only about 1% of the dose was found in the urine as triamcinolone acetonide.

Phenytoin prodrugs III: water-soluble prodrugs for oral and/or parenteral use

Various bioreversible derivatives of phenytoin, a poorly water soluble and erratically absorbed drug after both oral and parenteral dosing, were synthesized. Initial evaluation of these expected prodrugs, i.e., their aqueous solubility, cleavage in the presence of various animal tissues, and anticonvulsant activity in mice, confirmed that a number of the derivatives did indeed behave as prodrugs. The more promising prodrugs were the disodium phosphate ester and various amino groups containing acyl esters of 3-(hydroxymethyl)-5,5-diphenylhydantoin.

Disposition and metabolism of a new steroidal anti-inflammatory agent, deflazacort, in cynomolgus monkeys

The kinetics and metabolic fate of 2'-14C-deflazacort, a new steroidal antiinflammatory agent, were studied in the cynomolgus monkey after both p.o. and i.v. administration (5 mg/kg). There is no unchanged deflazacort in the plasma or urine after either p.o. or i.v. treatment. As judged from the plasma AUC and urinary elimination values, the oral availability of both total 14C and metabolites seems to be lowered because of a route-dependent first-pass. Both radioactivity and the main metabolite (21-desacetyl deflazacort) are eliminated from the plasma with half-lives of 2--3-5 h. The i.v. administered 14C is eliminated mainly in the urine (52--55% of dose), but biliary excretion is also quantitatively important. Six metabolites were isolated from urine and identified by physico-chemical analysis. Among them desacetylated deflazacort and its 6 beta-hydroxy derivative were shown to be the major radioactive products in plasma and urine, respectively. Minor metabolites were: 21-desacetyl, 6 alpha-hydroxy deflazacort; 21-desacetyl, 5 alpha, 1-eno, deflazacort; 21-desacetyl, 20 beta hydroxy deflazacort; and 21-desacetyl, 11-keto deflazacort.

Distribution and metabolism of triamcinolone acetonide in the rat embryomaternal unit during a teratogenically sensitive period

The distribution and metabolism of triamcinolone acetonide (TAC) in the rat embryomaternal unit were investigated during a teratogenically sensitive period. Pregnant rats (Day 12 of gestation) were injected im with 0.125 or 0.5 mg/kg [3H]TAC. Maternal plasma and embryos were collected at selected time points and analyzed by HPLC and liquid scintillation counting. No significant differences in the percentage of total radioactivity representing unchanged TAC, concentration of TAC, or its elimination half-life were detected in either plasma or embryos of the two dose groups. These results provide evidence that the metabolism and distribution of TAC in the rat embryomaternal unit are dose independent over this known teratogenic dose range. To determine whether multiple administration of TAC resulted in any alterations in maternal or embryonal exposure, the same parameters were evaluated following one (Day 12), two (Days 12 and 13), or three (Days 12, 13, and 14) injections of [3H]TAC (0.5 mg/kg, im). The only alterations detected were an increase in the percentage of total radioactivity in maternal plasma representing unchanged TAC at 1 hr following the second or third injection and an increase in the embryonal concentration of TAC at the same time points.

Influence of 16 alpha, 17 alpha-acetal substitution and steroid nucleus fluorination on the topical to systemic activity ratio of glucocorticoids

The use of topical glucocorticosteroid therapy on large skin areas or in the lung is sometimes restricted by the occurrence of unwanted, general corticoid actions owing to a profound systemic absorption. To decrease this risk potent glucocorticoids with an enhanced ratio between their topical and their systemic glucocorticoid potencies are wanted. Therefore, structure-activity studies were performed in rat models to investigate what influences the type of substitution in the 16 alpha, 17 alpha-acetal group and the introduction of fluorine in the 9 alpha- or the 6 alpha, 9 alpha-positions have on the topical and the systemic activities, respectively. The introduction of an unsymmetrical 16 alpha, 17 alpha-acetal group (named acetal type B) markedly enhanced the topical anti-inflammatory potency compared with that of the conventional 16 alpha, 17 alpha-acetonide group (named acetal type A). Both acetal types had a similar systemic glucocorticoid potency, however, 9 alpha-Fluoro and especially 6 alpha, 9 alpha-difluoro substitution, on the other hand, enhanced the systemic glucocorticoid activity more than they raised the topical anti-inflammatory potency. Optimal topical to systemic activity ratio was obtained with a nonhalogenated corticoid of acetal type B structure. This compound, budesonide, had at least the same high topical anti-inflammatory potency as fluocinolone acetonide but was about 10 times less potent than this reference to induce systemic glucocorticoid actions. Its lower systemic activity is probably due to a more rapid biotransformation in the liver.

In vitro biotransformation of glucocorticoids in liver and skin homogenate fraction from man, rat and hairless mouse

The pharmacological effects of glucocorticoids are greatly influenced by their pharmacokinetic properties. In the present report, the in vitro biotransformation of the topical glucocorticoids [3H]-budesonide ([3H]-BUD). [3H]-triamcinolone acetonide ([3H]-TAAc) and [3H]-hydrocortisone ([3H]-HC) was studied in the 9000 g liver and skin supernatant from man, rat and hairless mouse. The rate of disappearance of the compounds was estimated during the initial 30 min of incubation by high performance liquid chromatography. In human liver the half life (t1/2) rank order was [3H]-BUD (7--23 min) less than [3H]-TAAc (13--68 min) less than [3H]-HC (40--67 min), in rat liver [3H]-HC (14--21 min) less than [3H]-BUD (28--38 min) less than [3H]-TAAc (161--196 min) and in hairless mouse liver [3H]-BUD (17--22 min) less than [3H]-TAAc (21--34 min) less than [3H]-HC (82--165 min). Negligible biotransformation of these glucocorticoids occurred in skin. BUD is a one to one mixture of the [22R]- and [22S]-epimers. It was found that the [22R]-epimer was more susceptible to liver biotransformation than the [22S]-epimer of [3H]-BUD. The results are discussed with particular reference to the extent of systemic side effects of these compounds.

Separation of some natural and synthetic corticosteroids in biological fluids and tissues by high-performance liquid chromatography

A high-performance liquid chromatography (HPLC) technique was developed for the determination of radiolabeled triamcinolone acetonide (TAC), cortisol and their metabolites in rhesus monkey plasma, urine and tissue samples. After protein precipitation, the parent compounds and metabolites were simultaneously resolved using a single-column reversed-phase HPLC system. TAC was subsequently verified by mass spectrometry and TAC glucuronide was tentatively identified by enzymatic hydrolysis and mass spectrometry of the hydrolysis product. The endogenous hormones, cortisol and cortisone were presumptively identified by cochromatography with authentic standards on two different HPLC systems and positively identified by reverse-isotope recrystallization. Other metabolites of both compounds were detected by selective enzymatic hydrolysis and HPLC. This method is rapid and reproducible with a total recovery greater than 80%.

Disposition of a new steroidal anti-inflammatory agent, deflazacort, in rat, dog and man

The physiological disposition of a new steroid anti-inflammatory agent, deflazacort, was examined in rat, dog and man following 5 mg/kg doses to the animals, and 50 mg to humans. The administered radiocarbon [2'-14C]-deflazacort), is rapidly and extensively absorbed into the general circulation in rat and man, whereas the bioavailability in the dog is low. The terminal plasma half-life for radioactivity elimination was, on the average, 11, 15 and 28 hr in rats, dogs and man, respectively. Urinary excretion was the predominant route of 14C elimination in the rat (-54% of the dose) and in man (-68% of the dose), whereas in the dog the majority of the dose was eliminated via the feces (82%). Tissue distribution studies in the rat did not show target organs, with the exception of the blood cells. Studies of binding to plasma proteins of the 21-desacetyl deflazacort, demonstrate in all the species a rather low level of binding of non-saturable type.

The metabolic fate of triamcinolone acetonide in laboratory animals

The metabolic fate of 9-fluoro-11beta,16alpha,17,21-tetrahydroxy-1,4-pregnadiene-3,20-dione cyclic 16,17-acetal with 2(-14)C-acetone, triamcinolone acetonide (TA) was studied in rabbits, dogs, monkeys and rats and found to be qualitatively similar in all species. In the dog, rat and monkey the major excretory route was the feces irrespective of the mode of administration. In the rabbit the excreted radioactivity was equally distributed between urine and feces. The metabolites were isolated by preparative thin layer chromatography, located by autoradiography, eluted and analyzed by MS, IR, UV and NMR. The major metabolites of triamcinolone acetonide (TA) were identified as the C-21 carboxylic acids of TA and of the 6beta hydroxy-TA, (6BETA-OH-TA) and the previously identified (1,2) 6beta-OH-TA. In addition MS and UV data indicate the presence of 9-fluoro-11beta,16alpha, 17-trihydroxy-3,20-dioxo-1,4,6-pregnatrien-21-oic acid cyclic 16,17 acetal with 2(-14)C-acetone.