Drug interactions at excretory mechanisms

Diuretic treatment and diuretic resistance in heart failure

Diuretic therapy decreases capillary wedge pressure and improves New York Heart Association (NYHA) functional class both in acute and chronic heart failure. In advanced symptomatic heart failure, loop diuretics are generally necessary to improve symptoms of congestion. Diuretic resistance in the edematous patient has been defined as a clinical state in which diuretic response is diminished or lost before the therapeutic goal of relief from edema has been reached. The major causes of diuretic resistance are functional renal failure (prerenal azotemia), hyponatremia, altered diuretic pharmacokinetics, and sodium retention caused by counterregulatory mechanisms intended to reestablish the effective arterial blood volume. Therapeutic approaches to combat diuretic resistance include restriction of fluid and sodium intake, use of angiotensin-converting-enzyme (ACE) inhibitors, changes in route (oral, intravenous) and timing (single dose, multiple doses, continuous infusion) of diuretic therapy, and use of diuretic combinations.

Toxicological consequences of multiple chemical interactions: a primer

The capacity to understand and successfully predict the toxicological consequences of multiple chemical interactions is a critical challenge facing the scientific community. This article is designed to provide a broad framework introducing the concept of interaction, use of consistent and meaningful terminology and a descriptive assessment of toxicological foundations within which chemical interactions may be evaluated. The article offers guidance on the need to place a high priority on assessing the mechanistic basis of 'superinteractions', that is, unique interactions far exceeding even those of a multiplicative nature. The final section of the article provides a detailed perspective on how the extensive and successful experience of the pharmaceutical industry in assessing and interpreting any interaction for patients can be useful to the issues and concerns of chemical interactions for the field of environmental toxicology and risk assessment.

Decreased erythrocyte glutathione s-transferase activity in rubber workers

Decreased erythrocyte glutathione s-transferase activity was found in workers exposed to hot rubber fumes in two-roll mill and calender departments (6.6 +/- 0.9 and 6.8 +/- 0.8 mumol/min X mg haemoglobin, respectively vs 8.4 +/- 0.5 in controls). This trend was also noted in the general category of all rubber exposed workers without stratification according to their task (7.6 +/- 0.5, n = 30). This result was contrary to that expected, as the cases with the lowest values had the greatest urinary thioether excretion. The thioethers are the end-products of the enzyme-catalyzed glutathione conjugation reaction aimed at the inactivation of potentially toxic chemicals. Thus, it appears that the assay of erythrocyte glutathione s-transferase activity is not very informative about exposure, although the enzyme assay might disclose other, so far unknown, biological effects of reactive rubber chemicals.

Methods in testing interrelationships between excretion of drugs via urine and bile

The liver and kidney are largely responsible for inactivating and eliminating drugs and other chemicals. As the excretory capabilities of the two organs overlap, a damage of one system might be compensated by the other. Because of the specificity of both renal and hepatic elimination mechanisms such an alternative excretion route is not possible generally. Several interferences are possible to characterize the relation between hepatic and renal excretion of drugs and xenobiotics. Firstly, the simultaneous assay of excreted drug amounts in urine and bile can give some information concerning the main transport routes of this drug. Thereafter the total interruption of liver or kidney function elucidates the general possibility of alternative excretion routes. But it is important for clinical practice to distinguish between different localizations of organ damages. Today some experimental possibilities exist to exclude partial functions of both kidney and liver separately. Thus it can be clarified why a compound might be excreted via liver or kidney. Moreover it can be characterized whether or not a compensation for the loss of one main excretion organ is possible or not. Such investigations are of some practical importance. Dosing guidelines for drug therapy must be completed for cases of renal or hepatic failure. Moreover the developmental pattern of both elimination routes has consequences for drug use in paediatrics as well as geriatrics. Beside this point of view such investigations are necessary for the prediction of changes in the toxicity of drugs after renal or hepatic insufficiency.