Disposition of intravenous diazepam in young men and women

Slow Accumulation and Elimination of Diazepam and Its Active Metabolite With Extended Treatment in the Elderly

Age-related changes in disposition of diazepam and its principal active metabolite, desmethyldiazepam (DMDZ), during and after extended dosage with diazepam were studied in healthy volunteers. Eight elderly subjects (ages 61-78 years) and 7 young subjects (21-33 years) received 2.5 mg of diazepam twice daily for 15 days. Predose (trough) concentrations of diazepam and DMDZ were measured during the 15 days of dosing, and in the postdosage washout period. Kinetic properties were determined by nonlinear regression using a sequential drug-to-metabolite pharmacokinetic model. Steady-state plasma concentrations of diazepam and DMDZ were 30% to 35% higher in elderly subjects compared to young volunteers, and steady-state clearances correspondingly lower, though differences did not reach significance. Large and significant differences were found between young and elderly groups in mean half-life of diazepam (31 vs 86 hours; P < .005) and DMDZ (40 vs 80 hours; P < .02). Half-life values from the multiple-dose study were closely correlated with values from previous single-dose studies of diazepam (R² = 0.85) and DMDZ (R² = 0.94) in the same subjects. With extended dosing of diazepam in the elderly, slow accumulation and delayed washout of diazepam and DMDZ is probable. After discontinuation, withdrawal or rebound effects are reduced in likelihood, but delayed recovery from sedative effects is possible due to slow elimination of active compounds. Safe treatment of elderly patients with diazepam is supported by understanding of age-related changes in pharmacologic and pharmacokinetic properties.

Sex-dependent modulation of treatment response

The response to a psychotropic medication reflects characteristics of both the medication and the substrate, ie, the individual receiving the medication. Sex is an individual characteristic that influences all elements of the pharmacokinetic process - absorption, distribution, metabolism, and elimination. The effects of sex on these components of the pharmacokinetic process often counterbalance one another to yield minimal or varying sexual differences in blood levels achieved. However, sex also appears to influence pharmacodynamics, the tissue response to a given level of medication. Consideration by the practitioner of sex as a possible contributing factor to treatment nonresponse will enhance the efficacy and precision of clinical interventions.

[Sex differences relating to psychiatric treatment]

OBJECTIVE

This paper reviews the literature discussing the influence of gender factors on the efficacy of the most frequently used psychiatric treatments. It recommends taking into account patient gender in order to optimize the treatment efficacy and tolerance.

METHOD

Pharmaceutical and psychotherapeutic treatments as well as other types of therapy (psychosurgery, electroconvulsive therapy [ECT]) are discussed in the overview. Each section draws intermediate conclusions.

RESULTS

Literature on the subject is scarce and uneven. From a pharmaceutical perspective, gender differences are marked; they affect substance absorption, distribution, metabolism, and elimination. As a result, differences in bioavailability affect efficacy and side effects of antidepressants, neuroleptics, and lithium as well as of hypnotics, sedatives, and anxiolytics. The menstrual cycle and birth-control pills also produce significant interactions. Few studies have discussed the influence of the gender-specific effect on the outcome of psychotherapy. However, some differences might exist, and serious further research is required before repeatable conclusions can be reached. Patient gender does not seem to affect certain physical kinds of treatment such as psychosurgery or ETC as much.

CONCLUSIONS

Patient gender has a definite influence on the efficacy of the treatment administered. This influence, however, is often limited and should be considered for the optimization of treatment response and tolerance. Research in this field of psychiatry should be encouraged.

Recognition of depression in obstetric/gynecology practices

Depression is a common and serious health problem that occurs twice as often in women as in men. The lifetime prevalence of major depression in women is estimated to be as high as 21%. Although less severe and less common, mild depression and dysthymia (chronic mild depression) can cause functional disability and require treatment. Regardless of severity or duration, depression can be difficult to recognize because it frequently is masked by complaints that accompany other common obstetric and gynecologic illnesses and events. This article reviews the various depressive disorders in women with a focus on presentations that occur in obstetric and gynecologic practice.

Gender differences in diazepam withdrawal syndrome in mice

The present work was designed to study the influence of testosterone and oestrogens on the benzodiazepine withdrawal syndrome in mice. Several withdrawal signs were induced by 15 mg/kg intraperitoneally of flumazenil in diazepam-treated mice. The most noticeable were jerks, usually accompanied by tail lifts, and seizures. The intensity of the diazepam withdrawal syndrome was significantly lower in male than in female mice, especially in relation to the incidence of seizures. Castrated male mice showed a significant increase in the intensity of withdrawal syndrome. In addition, diazepam produced a significant increase of body weight in males but not in females. The principal finding of the present work is that the incidence of seizures produced by the administration of flumazenil was significantly lower in male than in female diazepam-treated mice. This fact suggests that the mechanism of action of benzodiazepines is modulated by the action of sexual hormones, and that testosterone plays a relevant role.

Influence of oral contraceptives on drug therapy

Interferences between drugs and oral contraceptives are considered to alter pharmacokinetics and thus the efficacy of steroidal hormones. It should be noted, however, that steroids can also modify the metabolism and pharmacodynamic effects of various substances. To the present knowledge, phase I (i.e., oxidation, demethylation) and phase II reactions (conjugation) are concerned. Drugs sharing those enzymatic systems with oral contraceptives experience either an increase in bioavailability by inhibition of oxidative metabolism or undergo accelerated elimination by induced conjugation. Such interaction may be of practical interest in subjects who take oral contraceptives and are simultaneously treated with antidepressants, antihypertensives, insulin, synthetic glucocorticoids, theophylline, and caffeine.

Sex-related differences in drug disposition in man

Sex-related differences in the disposition of some analgesics, anxiolytics and hypnotics have recently been reported. With certain benzodiazepines, sex has been shown to be a more important determinant of variability in drug disposition than age, while with other benzodiazepines an age-related decline in clearance was more pronounced in men than women. In young healthy adults these sex-related differences in drug disposition were related to the phase of the menstrual cycle, oral contraceptive steroid administration, and variations in plasma concentrations of albumin, alpha 1-acid glycoprotein, free fatty acids and sex hormones. While none of the sex-related differences so far reported necessitates the modification of a therapeutic dosage regimen, it is prudent that future protocols for pharmacokinetic studies should regard age, sex, the menstrual cycle and oral contraceptive steroids as potential sources of variability.

Managing drug interactions with oral contraceptives

An increasing concern to nurses is the possibility of drug interactions involving oral contraceptives. Information regarding the mechanisms, significance, and management of drug interactions with oral contraceptives is provided. Approaches to counseling patients also are discussed.

Pharmacokinetics of brotizolam in healthy subjects following intravenous and oral administration

Pharmacokinetics and bioavailability of brotizolam after i.v. and oral administration were studied in healthy young volunteers. Kinetic parameters after i.v. administration were: volume of distribution 0.66 +/- 0.19 1/kg, total plasma clearance 113 +/- 28 ml/min, distribution half-life 11 +/- 6 min, and elimination half-life 4.8 +/- 1.4 h (mean values +/- s.d.). Kinetic parameters after oral administration were: absorption lag-time 8 +/- 12 min, absorption half-life 10 +/- 11 min, and elimination half-life 5.1 +/- 1.2 h (mean values +/- s.d.). Bioavailability of brotizolam was 70 +/- 22% when calculated by comparing oral and intravenous area-under-curve values, corrected for intra-individual half-life differences. An alternative calculation method, which is relatively independent of large clearance variations, provided a bioavailability of 70 +/- 24% (range: 47-117%).