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Neumann J, Seidler T, Fehse C, Marušáková M, Hofmann B, Gergs U. Cardiovascular effects of metoclopramide and domperidone on human 5-HT 4-serotonin-receptors in transgenic mice and in human atrial preparations. Eur J Pharmacol 2021; 901:174074. [PMID: 33811834 DOI: 10.1016/j.ejphar.2021.174074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 11/16/2022]
Abstract
It is unclear whether metoclopramide and domperidone act on human cardiac serotonin 5-HT4-receptors. Therefore, we studied transgenic mice that only express the human 5-HT4 receptor in cardiomyocytes in the atrium and in the ventricle (5-HT4-TG), their wild type-littermates (WT) and isolated human atrial preparations. We found that only metoclopramide but not domperidone enhanced the force of contraction in left atrial preparations (pEC50 = 6.0 ± 0.1; n = 7) from 5-HT4-TG, isolated spontaneously beating right atrial preparations (pEC50 = 6.1 ± 0.1; n = 7) from 5-HT4-TG, Langendorff perfused hearts from 5-HT4-TG, living 5-HT4-TG and human right atrial muscle preparations obtained during bypass surgery of patients suffering from coronary heart disease. The maximum inotropic effect of metoclopramide was smaller (81 ± 2%) than that of 5-HT on the left atria from 5-HT4-TG. The maximum increase in the beating rate due to metoclopramide was 93 ± 2% of effect of 5-HT on right atrial preparations from 5-HT4-TG. Metoclopramide and domperidone were inactive in WT. We found that metoclopramide but not domperidone increased the phosphorylation state of phospholamban in the isolated perfused hearts or muscle strips of 5-HT4-TG, but not in WT. Metoclopramide, but not domperidone, shifted the positive inotropic or chronotropic effects of 5-HT in isolated left atrial and right atrial preparations from 5-HT4-TG dextrally, resp., to higher concentrations: the pEC50 of 5-HT for increase in force was in the absence of metoclopramide 8.6 ± 0.1 (n = 5) versus 8.0 ± 0.3 in the presence of 1 μM metoclopramide (n = 5; P < 0.05); and the beating rate was 7.8 ± 0.2 (n = 7) in the absence of metoclopramide versus 7.2 ± 0.1 in the presence of 1 μM metoclopramide (n = 6; P < 0.05). These results suggested that metoclopramide had an antagonistic effect on human cardiac 5-HT4 receptors. In summary, we showed that metoclopramide, but not domperidone, was a partial agonist at human cardiac 5-HT4-receptors.
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Affiliation(s)
- Joachim Neumann
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, D-06097, Halle, Germany
| | - Tom Seidler
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, D-06097, Halle, Germany
| | - Charlotte Fehse
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, D-06097, Halle, Germany
| | - Margaréta Marušáková
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, D-06097, Halle, Germany; Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Slovakia
| | - Britt Hofmann
- Cardiac Surgery, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, D-06097, Halle, Germany
| | - Ulrich Gergs
- Institut für Pharmakologie und Toxikologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, D-06097, Halle, Germany.
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Riether C, Radpour R, Kallen NM, Bürgin DT, Bachmann C, Schürch CM, Lüthi U, Arambasic M, Hoppe S, Albers CE, Baerlocher GM, Ochsenbein AF. Metoclopramide treatment blocks CD93-signaling-mediated self-renewal of chronic myeloid leukemia stem cells. Cell Rep 2021; 34:108663. [PMID: 33503440 DOI: 10.1016/j.celrep.2020.108663] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 11/20/2020] [Accepted: 12/28/2020] [Indexed: 12/17/2022] Open
Abstract
Self-renewal is a key characteristic of leukemia stem cells (LSCs) responsible for the development and maintenance of leukemia. In this study, we identify CD93 as an important regulator of self-renewal and proliferation of murine and human LSCs, but not hematopoietic stem cells (HSCs). The intracellular domain of CD93 promotes gene transcription via the transcriptional regulator SCY1-like pseudokinase 1 independently of ligation of the extracellular domain. In a drug library screen, we identify the anti-emetic agent metoclopramide as an efficient blocker of CD93 signaling. Metoclopramide treatment reduces murine and human LSCs in vitro and prolongs survival of chronic myeloid leukemia (CML) mice through downregulation of pathways related to stemness and proliferation in LSCs. Overall, these results identify CD93 signaling as an LSC-specific regulator of self-renewal and proliferation and a targetable pathway to eliminate LSCs in CML.
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Affiliation(s)
- Carsten Riether
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland.
| | - Ramin Radpour
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Nils M Kallen
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Damian T Bürgin
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Chantal Bachmann
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland; Graduate School of Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Christian M Schürch
- Baxter Laboratory for Stem Cell Biology, Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ursina Lüthi
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Miroslav Arambasic
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Sven Hoppe
- Wirbelsäulenmedizin Bern, Hirslanden Salem-Spital, Bern, Switzerland; Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph E Albers
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gabriela M Baerlocher
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland; Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adrian F Ochsenbein
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland.
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Hayward KL, Weersink RA. Improving Medication-Related Outcomes in Chronic Liver Disease. Hepatol Commun 2020; 4:1562-1577. [PMID: 33163829 PMCID: PMC7603526 DOI: 10.1002/hep4.1612] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/20/2020] [Accepted: 09/08/2020] [Indexed: 12/17/2022] Open
Abstract
Patients with chronic liver disease (CLD) are becoming increasingly complex due to the rising prevalence of multimorbidity and polypharmacy. Medications are often essential to manage the underlying liver disease, complications of cirrhosis and portal hypertension, and comorbidities. However, medication-related problems (MRPs) have been associated with adverse patient outcomes, including hospitalization and mortality. Factors that can contribute to MRPs in people with CLD are variable and often entwined. This narrative literature review discusses key barriers and opportunities to modify risk factors and improve medication-related outcomes for people with CLD.
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Affiliation(s)
- Kelly L Hayward
- Centre for Liver Disease Research, Faculty of Medicine The University of Queensland, Translational Research Institute Brisbane QLD Australia.,Department of Gastroenterology and Hepatology Princess Alexandra Hospital Brisbane QLD Australia
| | - Rianne A Weersink
- Department of Clinical Pharmacy Deventer Hospital Deventer The Netherlands
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Ge S, Mendley SR, Gerhart JG, Melloni C, Hornik CP, Sullivan JE, Atz A, Delmore P, Tremoulet A, Harper B, Payne E, Lin S, Erinjeri J, Cohen-Wolkowiez M, Gonzalez D. Population Pharmacokinetics of Metoclopramide in Infants, Children, and Adolescents. Clin Transl Sci 2020; 13:1189-1198. [PMID: 32324313 PMCID: PMC7719387 DOI: 10.1111/cts.12803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/06/2020] [Indexed: 11/26/2022] Open
Abstract
Metoclopramide is commonly used for gastroesophageal reflux. The aims of the present study were to develop a pediatric population pharmacokinetic (PopPK) model, which was applied to simulate the metoclopramide exposure following dosing used in clinical practice. Opportunistic pharmacokinetic data were collected from pediatric patients receiving enteral or parenteral metoclopramide per standard of care and these data were simultaneously fitted using NONMEM. Allometric scaling with body weight was included a priori in the model. Using the final model, the steady‐state maximum concentrations (Css,max) and the area under the metoclopramide plasma concentration‐time curve at steady state from 0 to 6 hours (AUCss,0–6h) were simulated following 0.1 or 0.15 mg/kg orally every 6 hours in virtual patients, and compared with previously reported ranges associated with toxicity or the efficacy for gastroesophageal reflux in infants. A two‐compartment model with first‐order absorption best characterized 87 concentration measurements from 50 patients (median [range] postnatal age of 8.89 years [0.01–19.13]). There were 20 infants (≤ 2 years), 9 children (2 years to age ≤ 12 years), and 21 adolescents (> 12 years). Body weight was the only covariate included in the final model. For > 75% of virtual patients, simulated Css,max and AUCss,0–6h estimates were within the range associated with efficacy for gastroesophageal reflux in infants; however, slightly lower exposures were predicted in virtual patients < 2 years. Our study suggests that a metoclopramide enteral dose of 0.1 mg/kg every 6 hours, which was previously recommended for pediatric patients, results in simulated exposure generally within suggested ranges for the treatment of gastroesophageal reflux.
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Affiliation(s)
- Shufan Ge
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susan R Mendley
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jacqueline G Gerhart
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Chiara Melloni
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Janice E Sullivan
- Kosair Charities Pediatric Clinical Research Unit, Department of Pediatrics, University of Louisville, Louisville, Kentucky, USA.,Norton Children's Hospital, Louisville, Kentucky, USA
| | - Andrew Atz
- Medical University of South Carolina Children's Hospital, Charleston, South Carolina, USA
| | | | - Adriana Tremoulet
- School of Medicine, University of California-San Diego, San Diego, California, USA
| | - Barrie Harper
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Susan Lin
- The Emmes Company, LLC, Rockville, Maryland, USA
| | | | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Al-Saffar A, Lennernäs H, Hellström PM. Gastroparesis, metoclopramide, and tardive dyskinesia: Risk revisited. Neurogastroenterol Motil 2019; 31:e13617. [PMID: 31050085 DOI: 10.1111/nmo.13617] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 04/13/2019] [Accepted: 04/17/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Metoclopramide is primarily a dopamine receptor antagonist, with 5HT3 receptor antagonist and 5HT4 receptor agonist activity, and used as an antiemetic and gastroprokinetic since almost 50 years. Regulatory authorities issued restrictions and recommendations regarding long-term use of the drug at oral doses exceeding 10 mg 3-4 times daily because of the risk for development of tardive dyskinesia. The aim of our study was to review mechanism(s) of action and pharmacokinetic-pharmacodynamic properties of metoclopramide, as well as the risk of metoclopramide-induced tardive dyskinesia, factors that may change drug exposure in humans, and to summarize the clinical context for appropriate use of the drug. METHODS A PubMed, Google Scholar, and Cross Reference search was done using the key words and combined searches: drug-drug interaction, gastroparesis, metoclopramide, natural history, pharmacokinetics, pharmacodynamics, drug-drug interaction, outcome, risk factors, tardive dyskinesia. KEY RESULTS Data show that the risk of tardive dyskinesia from metoclopramide is low, in the range of 0.1% per 1000 patient years. This is far below a previously estimated 1%-10% risk suggested in treatment guidelines by regulatory authorities. High-risk groups are elderly females, diabetics, patients with liver or kidney failure, and patients with concomitant antipsychotic drug therapy, which reduces the threshold for neurological complications. CONCLUSIONS & INFERENCES The risk of tardive dyskinesia due to metoclopramide is far below approximated numbers in treatment guidelines. This risk and the influence of known risk factors should be considered when starting a course of metoclopramide for treatment of gastroparesis.
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Affiliation(s)
- Ahmad Al-Saffar
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Hans Lennernäs
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Per M Hellström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Wilcock A, Charlesworth S, Prentice W, Selby P, McKenna M, Cripps S, Considine A, Orr A, Wright M, Mihalyo M, Oxberry S. Prescribing in Chronic Severe Hepatic Impairment. J Pain Symptom Manage 2019; 58:515-537. [PMID: 31077785 DOI: 10.1016/j.jpainsymman.2019.04.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 04/29/2019] [Indexed: 12/29/2022]
Abstract
Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available via www.palliativedrugs.com. The series editors welcome feedback on the articles.
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Affiliation(s)
- Andrew Wilcock
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom.
| | - Sarah Charlesworth
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Wendy Prentice
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Paul Selby
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Maria McKenna
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Sarah Cripps
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Aisling Considine
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Alison Orr
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Mark Wright
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Mary Mihalyo
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
| | - Stephen Oxberry
- University of Nottingham (A.W.), Nottingham, United Kingdom; Pharmaceutical Press (S.Ch.), London, United Kingdom; Kings College Hospital (W.P.), London, United Kingdom; Cambridge University Hospital NHS Trust (P.S.), Cambridge, United Kingdom; Freeman Hospital (M.M), Newcastle Upon Tyne, United Kingdom; Oxford University Hospitals NHS Foundation Trust (S.Cr.), Oxford, United Kingdom; Kings College Hospital (A.C.), London, United Kingdom; Kings College Hospital (A.O.), London, United Kingdom; University Hospitals, Southampton (M.W.), Southampton, United Kingdom; Mylan School of Pharmacy, Duquesne University (M.M.), Pittsburgh, Pennsylvania, USA; Kirkwood Hospice (S.O.) Huddersfield, United Kingdom
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Impact of Safety Warning on Domperidone Prescribing for Geriatric Patients in South Korea: Analysis of National Insurance Claim Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16162985. [PMID: 31434200 PMCID: PMC6719182 DOI: 10.3390/ijerph16162985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/14/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
Abstract
Domperidone is a dopamine antagonist used for the symptomatic management of nausea and vomiting. Many countries banned or add a black box warning due to an increased risk of serious adverse cardiac effects. In 2014, the Korea Ministry of Food and Drug Safety also released a safety warning to carefully consider adverse cardiac effects when prescribing domperidone. Therefore, we conducted this study to analyze the impact of the safety warning on domperidone prescribing. This study included patients 65 years or older who used national health insurance services in the years 2011 and 2016, using the national patient sample dataset in South Korea. We analyzed the characteristics of domperidone prescribing and compared on pre- and post-safety warning. Prescribing frequency of domperidone was significantly reduced from 603,962 cases in 2011 to 24,623 cases in 2016. In 2011, 53,272 (8.8%) prescriptions were for greater than 30 mg/day, whereas only 200 (0.8%) prescriptions were in 2016. The number of patients with one or more comorbidities and electrocardiogram monitoring showed positive changes after the safety warning. In conclusion, after the 2014 safety letter was issued, domperidone was more safely prescribed in various aspects in elderly patients, including frequency of prescribing, maximum daily dose, and duration of continuous prescription.
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Shakhatreh M, Jehangir A, Malik Z, Parkman HP. Metoclopramide for the treatment of diabetic gastroparesis. Expert Rev Gastroenterol Hepatol 2019; 13:711-721. [PMID: 31314613 DOI: 10.1080/17474124.2019.1645594] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Introduction: Gastroparesis is a chronic disorder of the stomach characterized by delayed gastric emptying without mechanical obstruction. Diabetes is the most commonly known cause of gastroparesis. Management of diabetic gastroparesis involves lifestyle modifications, glycemic control, pharmacological drugs, and for refractory cases surgical treatments. Metoclopramide remains the only drug approved by the Food and Drug Administration for diabetic gastroparesis. The aim of this article is to provide a concise review of the pharmacology, clinical efficacy and tolerability of metoclopramide. Areas covered: We searched PubMed using the key words 'metoclopramide', 'diabetic gastroparesis', and 'gastric emptying'. The relevant articles and their bibliography were reviewed. Metoclopramide acts on several different receptors; primarily as a dopamine receptor antagonist, both peripherally improving gastric emptying, and centrally resulting in an anti-emetic effect. Metoclopramide side effects, mostly related to its ability to cross the blood-brain barrier, include drowsiness, restlessness, hyperprolactinemia, and tardive dyskinesia (TD), a movement disorder that may be irreversible. Expert opinion: Metoclopramide carries a black box warning for use >12 weeks due to the risk of TD. However, gastroparesis patients experience chronic symptoms often requiring prolonged treatments. Physicians and patients look forward to FDA approval of new agents for gastroparesis with better efficacy and safety profile.
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Affiliation(s)
- Mohammed Shakhatreh
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
| | - Asad Jehangir
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
| | - Zubair Malik
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
| | - Henry P Parkman
- a GI Section, Department of Medicine, Temple University School of Medicine , Philadelphia , PA , USA
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Positron Emission Tomography Imaging Reveals an Importance of Saturable Liver Uptake Transport for the Pharmacokinetics of Metoclopramide. CONTRAST MEDIA & MOLECULAR IMAGING 2018; 2018:7310146. [PMID: 29853808 PMCID: PMC5964550 DOI: 10.1155/2018/7310146] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/14/2018] [Accepted: 04/02/2018] [Indexed: 12/14/2022]
Abstract
Positron emission tomography (PET) imaging using [11C]metoclopramide, a P-glycoprotein (P-gp) substrate, was used to investigate the contribution of transport processes to metoclopramide liver clearance. The liver kinetics obtained after injection of [11C]metoclopramide were measured using PET in rats (n=4‐5) in the absence (tracer dose) and the presence of a pharmacologic dose of metoclopramide (3 mg/kg), with or without P-gp inhibition using i.v. tariquidar (8 mg/kg). Corresponding [11C]metoclopramide kinetics and metabolism in plasma (n=3) were measured using radio-HPLC analysis. [11C]metoclopramide exposure to the liver and plasma was described by the area under the time-activity curve (AUC) of the radioactivity kinetics in the liver and parent [11C]metoclopramide kinetics in plasma, respectively. The pharmacologic dose of metoclopramide resulted in a ∼2.2-fold increase in [11C]metoclopramide AUCplasma, while P-gp inhibition did not. AUCliver was lower using the pharmacologic dose (42.9 ± 13.8 SUV·min) compared with the tracer dose (210.0 ± 32.4 SUV·min). P-gp inhibition enhanced the liver exposure in the pharmacologic condition only (81.0 ± 3.1 SUV·min). [11C]metoclopramide PET imaging suggests an unpredicted role for hepatocyte uptake transporter(s) in controlling metoclopramide pharmacokinetics in addition to the known contribution of the metabolic enzymes and the P-gp.
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A Prediction Model of Drug Exposure in Cirrhotic Patients According to Child-Pugh Classification. Clin Pharmacokinet 2016; 54:1245-58. [PMID: 26070946 DOI: 10.1007/s40262-015-0288-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Prediction of drug clearance in liver cirrhosis patients is currently based on in vitro-in vivo extrapolation and physiologically-based pharmacokinetic models. No static model for this purpose has been described. The objectives of this study were to (1) derive a static model for predicting drug exposure in cirrhotic patients, and (2) to evaluate the model on a large set of published data. METHODS The impact of cirrhosis was characterized by the ratio of the total and unbound drug area under the concentration-time curve (AUC) in cirrhotic patients to the AUC measured in healthy subjects These ratios were predicted for Child-Pugh classes A, B, and C. The AUC ratios observed in published data were compared with AUC ratios predicted by the model. RESULTS Among 171 drugs examined, 83 published AUC ratios for 45 drugs in cirrhotic patients were available for analysis. The mean ± standard deviation relative prediction error for the total and unbound AUC ratios was 0.22 ± 0.58 and 0.24 ± 0.56, respectively. There were four outliers among the 83 predicted values. Simulations showed that the prediction error was negligible provided that the hepatic extraction coefficient was less than 0.8. CONCLUSIONS For mild and moderate cirrhosis (classes A and B), the predicted unbound AUC ratio is typically approximately 2 and 3.5, respectively, for most drugs. In the absence of data in cirrhotic patients, the drug dose might be empirically reduced by these factors. In severe cirrhosis (class C), our model may help clinicians to adjust their prescriptions.
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Vito VD, Kim TW, Rota S, Giorgi M. Pharmacokinetics of Metoclopramide After IntraARTERIAL, Intramuscular, Subcutaneous, and Perrectal Administration in Rabbits. J Exot Pet Med 2015. [DOI: 10.1053/j.jepm.2015.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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HAMAMOTO K, MIZUNO Y, KATO M, YAMAGISHI N, FURUHAMA K. Simple and Sensitive Method for Measurement of Metoclopramide in Cattle Plasma by LC-MS/MS Using a Multimode Chromatography. J Vet Med Sci 2013; 75:509-13. [DOI: 10.1292/jvms.12-0220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Kouko HAMAMOTO
- National Veterinary Assay Laboratory, Ministry of Agriculture, Forestry and Fisheries, 1–15–1 Tokura, Kokubunji, Tokyo 185–8511, Japan
| | - Yasuharu MIZUNO
- National Veterinary Assay Laboratory, Ministry of Agriculture, Forestry and Fisheries, 1–15–1 Tokura, Kokubunji, Tokyo 185–8511, Japan
| | - Masaki KATO
- Department of Veterinary Basic Medicine, Faculty of Agriculture, Iwate University, 3–18–8 Ueda, Morioka, Iwate 020–8550, Japan
| | - Norio YAMAGISHI
- Department of Veterinary Clinical Medicine, Faculty of Agriculture, Iwate University, 3–18–8 Ueda, Morioka, Iwate 020–8550, Japan
| | - Kazuhisa FURUHAMA
- Department of Veterinary Basic Medicine, Faculty of Agriculture, Iwate University, 3–18–8 Ueda, Morioka, Iwate 020–8550, Japan
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Glare P, Miller J, Nikolova T, Tickoo R. Treating nausea and vomiting in palliative care: a review. Clin Interv Aging 2011; 6:243-59. [PMID: 21966219 PMCID: PMC3180521 DOI: 10.2147/cia.s13109] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Nausea and vomiting are portrayed in the specialist palliative care literature as common and distressing symptoms affecting the majority of patients with advanced cancer and other life-limiting illnesses. However, recent surveys indicate that these symptoms may be less common and bothersome than has previously been reported. The standard palliative care approach to the assessment and treatment of nausea and vomiting is based on determining the cause and then relating this back to the "emetic pathway" before prescribing drugs such as dopamine antagonists, antihistamines, and anticholinergic agents which block neurotransmitters at different sites along the pathway. However, the evidence base for the effectiveness of this approach is meager, and may be in part because relevance of the neuropharmacology of the emetic pathway to palliative care patients is limited. Many palliative care patients are over the age of 65 years, making these agents difficult to use. Greater awareness of drug interactions and QT(c) prolongation are emerging concerns for all age groups. The selective serotonin receptor antagonists are the safest antiemetics, but are not used first-line in many countries because there is very little scientific rationale or clinical evidence to support their use outside the licensed indications. Cannabinoids may have an increasing role. Advances in interventional gastroenterology are increasing the options for nonpharmacological management. Despite these emerging issues, the approach to nausea and vomiting developed within palliative medicine over the past 40 years remains relevant. It advocates careful clinical evaluation of the symptom and the person suffering it, and an understanding of the clinical pharmacology of medicines that are available for palliating them.
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Affiliation(s)
- Paul Glare
- Pain and Palliative Care Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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14
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Abstract
BACKGROUND Metoclopramide is a dopamine receptor antagonist which has been used for treatment of a variety of gastrointestinal symptoms over the last thirty years. In 2009, the FDA issued a black box warning regarding long-term or high-dose use of this medication because of the risk of developing tardive dyskinesia. AIMS To review the mechanism of action and pharmacokinetic properties of metoclopramide, the risk of metoclopramide-induced tardive dyskinesia, potential mechanisms that may alter and to summarize the clinical context for appropriate use of the drug. METHODS We conducted a PubMed search using the following key words and combined searches: metoclopramide, neuroleptics, tardive dyskinesia, incidence, prevalence, dopamine, receptors, pharmacokinetic, pharmacology, pharmacogenetics, DRD3 Ser9Gly polymorphism, cytochrome P450, p-glycoprotein, risk factors, gastroparesis, outcome, natural history. RESULTS Available data show that risk of tardive dyskinesia from metoclopramide use is likely to be <1%, much less than the estimated 1-10% risk previously suggested in national guidelines. Tardive dyskinesia may represent an idiosyncratic response to metoclopramide; pharmacogenetics affect pharmacokinetic and dopamine receptor pharmacodynamics in response to neuroleptic agents that cause similar neurological complications. CONCLUSION Community prevalence and pharmacogenetic mechanisms involved in metoclopramide-induced tardive dyskinesia require further study to define the benefit-risk ratio more clearly.
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Affiliation(s)
- A S Rao
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), College of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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15
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Abstract
Gastroparesis is a chronic disorder that affects a significant subset of the population. Diabetes mellitus is a risk factor for the development of gastroparesis. Currently, metoclopramide is the only US FDA-approved medication for the treatment of gastroparesis. However, the FDA recently placed a black-box warning on metoclopramide because of the risk of related side effects, including tardive dyskinesia, the incidence of which has been cited to be as high as 15% in the literature. This review will investigate the mechanisms by which metoclopramide improves the symptoms of gastroparesis and will focus on the evidence of clinical efficacy supporting metoclopramide use in gastroparesis. Finally, we seek to document the true complication risk from metoclopramide, especially tardive dyskinesia, by reviewing the available evidence in the literature. Potential strategies to mitigate the risk of complications from metoclopramide will also be discussed.
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Affiliation(s)
- Allen Lee
- Tufts Medical Center, Boston, MA, USA
| | - Braden Kuo
- Massachusetts General Hospital, Blake 4, 55 Fruit St, Boston, MA 02114, USA
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16
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Glare PA, Dunwoodie D, Clark K, Ward A, Yates P, Ryan S, Hardy JR. Treatment of nausea and vomiting in terminally ill cancer patients. Drugs 2009; 68:2575-90. [PMID: 19093700 DOI: 10.2165/0003495-200868180-00004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Nausea and vomiting is a common and distressing symptom complex in patients with far-advanced cancer, affecting up to 60% of individuals at some stage of their illness. The current approach to the palliative care of patients with nausea and vomiting is based on identifying the cause, understanding its pathophysiology and knowing the pharmacology of the drugs available for its amelioration. The following six main syndromes are identified: gastric stasis, biochemical, raised intracranial pressure, vestibular, mechanical bowel obstruction and ileus. A careful history, focused physical examination and appropriate investigations are needed to elucidate the syndrome and its cause, so that therapy is rational. Drugs are the mainstay of treatment in terminal cancer, and the main classes of antiemetic agents are prokinetics, dopamine antagonists, antihistamines, anticholinergics and serotonin antagonists. Dexamethasone and octreotide are also used, especially in bowel obstruction. Non-drug measures are important in relieving the associated distress. Patients should be able to die comfortably, without tubes. Despite decades of practice affirming this approach, the evidence base is weak and well designed studies are urgently needed.
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Affiliation(s)
- Paul A Glare
- Pain and Palliative Care Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York 10021, USA.
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Abstract
Liver disease can modify the kinetics of drugs biotransformed by the liver. This review updates recent developments in this field, with particular emphasis on cytochrome P450 (CYP). CYP is a rapidly expanding area in clinical pharmacology. The information currently available on specific isoforms involved in drug metabolism has increased tremendously over the latest years, but knowledge remains incomplete. Studies on the effects of liver disease on specific isoenzymes of CYP have shown that some isoforms are more susceptible than others to liver disease. A detailed knowledge of the particular isoenzyme involved in the metabolism of a drug and the impact of liver disease on that enzyme can provide a rational basis for dosage adjustment in patients with hepatic impairment. The capacity of the liver to metabolise drugs depends on hepatic blood flow and liver enzyme activity, both of which can be affected by liver disease. In addition, liver failure can influence the binding of a drug to plasma proteins. These changes can occur alone or in combination; when they coexist their effect on drug kinetics is synergistic, not simply additive. The kinetics of drugs with a low hepatic extraction are sensitive to hepatic failure rather than to liver blood flow changes, but drugs having a significant first-pass effect are sensitive to alterations in hepatic blood flow. The drugs examined in this review are: cardiovascular agents (angiotensin converting enzyme inhibitors, angiotensin II receptor antagonists, calcium antagonists, ketanserin, antiarrhythmics and hypolipidaemics), diuretics (torasemide), psychoactive and anticonvulsant agents (benzodiazepines, flumazenil, antidepressants and tiagabine), antiemetics (metoclopramide and serotonin antagonists), antiulcers (acid pump inhibitors), anti-infectives and antiretroviral agents (grepafloxacin, ornidazole, pefloxacin, stavudine and zidovudine), immunosuppressants (cyclosporin and tacrolimus), naltrexone, tolcapone and toremifene. According to the available data, the kinetics of many drugs are altered by liver disease to an extent that requires dosage adjustment; the problem is to quantify the required changes. Obviously, this requires the evaluation of the degree of hepatic impairment. At present there is no satisfactory test that gives a quantitative measure of liver function and its impairment. A critical evaluation of these methods is provided. Guidelines providing a rational basis for dosage adjustment are illustrated. Finally, it is important to consider that liver disease not only affects pharmacokinetics but also pharmacodynamics. This review also examines drugs with altered pharmacodynamics.
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Affiliation(s)
- V Rodighiero
- Department of Pharmacology, University of Padova, Italy
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18
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Abstract
BACKGROUND/AIMS There is evidence to suggest that not all pathways of drug metabolism are similarly affected in cirrhosis. The effect of cirrhosis on drug oxidation and glucuronidation has been extensively investigated but little is known of the effect of cirrhosis on drug sulphation. The aim of this study was to investigate the effect of cirrhosis on sulphation. METHODS We investigated the effect of cirrhosis on p-nitrophenol sulphation and compared this with the effect of cirrhosis on p-nitrophenol glucuronidation as well as on d-propranolol oxidation simultaneously in the single-pass isolated perfused rat liver. The perfusate contained added inorganic sulphate to maximise production of p-nitrophenol sulphate. RESULTS About 77% and 59% of p-nitrophenol was eliminated as the sulphate conjugate by the healthy (n=6) and cirrhotic (n=7) livers, respectively. Mean total p-nitrophenol clearance was decreased in cirrhosis (healthy: 18.5+/-0.2 vs. cirrhotic 15.3+/-4.0 ml/min; p<0.05). The decrease in total clearance of p-nitrophenol was due solely to the decrease in sulphate formation clearance, which was significantly decreased (healthy: 14.1+/-1.9 vs. cirrhotic: 9.27+/-3.33 ml/min; p<0.05). Mean glucuronide formation clearance (healthy: 5.11+/-0.94 vs cirrhotic: 5.79+/-0.85 ml/ min; p>0.05) was not significantly altered. Mean total propranolol clearance was decreased in cirrhosis (healthy: 19.9+/-0.1 vs. cirrhotics: 18.0+/-1.5 ml/min; p<0.05). CONCLUSIONS We have shown that in cirrhosis there is significant impairment of drug oxidation and sulphation, whilst glucuronidation is spared. The decreased sulphation of p-nitrophenol was most likely due to a decrease in phenol sulphotransferase and/or decrease in cofactor synthesis.
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Affiliation(s)
- E F Choo
- Department of Pharmaceutics, Victorian College of Pharmacy, Monash University, Melbourne, Australia
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19
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Abstract
Cirrhosis encompasses a range of pathophysiological changes that may alter drug disposition. Drugs that are dependent primarily on the liver for their systemic clearance are more likely to be subject to reduced elimination and subsequent accumulation. Drug accumulation may lead to excessive plasma drug concentrations and adverse effects, if the adverse effects of the drug are concentration-dependent. The effects of hepatic insufficiency on the pharmacokinetics of drugs are not consistent or predictable. Furthermore, the influence of hepatic disease on the disposition of various drugs can vary, even though those drugs may share the same apparent metabolic pathway. Problems in forecasting drug kinetic behaviour are further enhanced by the additional impairment of kidney function (frequently encountered in patients with advanced liver disease) and by the unpredictability of the glomerular filtration rate using customary methods in patients with cirrhosis. Accordingly, dosages are generally adapted empirically, with the help of serum drug concentrations, when applicable. However, drugs eliminated predominantly by hepatic metabolism are not among those most commonly inducing adverse drug reactions or causing severe complications in patients with cirrhosis. Electrolyte disturbances and the hepatorenal syndrome produced by furosemide (frusemide)-the disposition of which is not substantially modified in liver disease-appear to be the most frequent adverse drug reactions in patients with liver disease. Furthermore, clinically significant alterations in the action of medications at concentrations generally considered to be in the normal therapeutic range are not uncommon. Tissue responsiveness to the pharmacological action of some drugs may be modified, as evidenced by the increased susceptibility of the brain in patients with cirrhosis to the action of many psychoactive agents. Another example is the greater susceptibility of such patients to the nephrotoxic potential of aminogly-cosides, which should not be used in this patient group. Drugs may also interfere with adaptive physiological processes induced by liver disease. ACE inhibitors and nonsteroidal anti-inflammatory drugs counteract the enhanced activity of the renin-angiotensin system in advanced liver disease, thereby generating a high risk of excessive hypotension or acute renal failure, respectively. These drugs are best avoided in patients with cirrhosis. Finally, there may be pharmacological effects that overlap with some pathophysiological modifications related to the process of liver disease, such as increased portal pressure produced by some calcium antagonists, or hypoprothrombinaemia related to the inhibition of synthesis of vitamin K-dependent clotting factors by some beta-lactam antibacterials (especially moxalactam and cefamandole). Accordingly, the use of these drugs should be avoided in advanced liver disease. It is noteworthy that reduced drug metabolism in patients with liver disease does not seem to have a significant impact on the frequency of hepatotoxicity. Special caution should be exercised, however, in patients with alcoholic liver disease because excessive alcohol intake may potentiate the hepatotoxic effect of paracetamol (acetaminophen).
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Affiliation(s)
- J F Westphal
- Internal Medicine Service, University Hospitals of Strasbourg, France
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Auprayoon P, Sukontason K, Na-Bangchang K, Banmairuroi V, Molunto P, Karbwang J. Pharmacokinetics of quinine in chronic liver disease. Br J Clin Pharmacol 1995; 40:494-7. [PMID: 8703656 PMCID: PMC1365198 DOI: 10.1111/j.1365-2125.1995.tb05795.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The pharmacokinetics of quinine were investigated in a) six healthy male Thai subjects, and b) nine male Thai patients with a moderate degree of chronic liver disease, after a single oral dose of 600 mg quinine sulphate. tmax and t1/2.2 were significantly prolonged in patients (median [range] tmax 2 [1-5] vs 1.6 [0.8-2] h; t1/2,z 23.4 [17.4-41.7] vs 9.7 [7.8-17.2] h), and Vz/F was significantly larger (median [range] 4.21 [2.33-15.87] vs 2.78 [1.49-3.38] 1 kg-1). Median (range) concentration of the plasma unbound Qn fraction collected from the patients at 4 h after drug administration was 17 (8.4-17.8)% of total drug concentration.
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Affiliation(s)
- P Auprayoon
- Department of Medicine, Prapokklao Hospital, Chantaburi Province, Thailand
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Morgan DJ, McLean AJ. Clinical pharmacokinetic and pharmacodynamic considerations in patients with liver disease. An update. Clin Pharmacokinet 1995; 29:370-91. [PMID: 8582120 DOI: 10.2165/00003088-199529050-00005] [Citation(s) in RCA: 164] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The effects of liver disease on pharmacokinetics and pharmacodynamics are highly variable, and difficult to predict as the mechanisms of these effects are not well understood. Since the majority of the published literature is concerned with cirrhotic liver disease, this review also focuses mainly on this area. Four different theories have been proposed to account for the effects of chronic liver disease with cirrhosis on hepatic drug elimination: the sick cell theory; the intact hepatocyte theory; the impaired drug uptake theory; and the oxygen limitation theory. While some data in support of each of the first 2 theories have been published recently, a large amount of clinical data would appear to refute both of these theories. These clinical data are substantially consistent with the latter 2 theories, which regard the decreased permeability of the capillarised sinusoid as the critical feature in cirrhosis. Further work is required to determine the applicability of each of these theories. In cirrhosis, drug glucuronidation is spared relative to oxidative drug metabolism; however, in advanced cirrhosis this pathway may also be impaired substantially. There is evidence that in cirrhosis other conjugation pathways may also be impaired to variable degrees. Growing evidence suggests that biliary drug excretion is impaired in cirrhosis. Recent studies with several racemic drugs indicate that the disease can have different effects on the hepatic elimination of individual enantiomers, which may lead to a change in the concentration-response relationships of racemic drugs in cirrhosis. A major finding which has emerged in recent years is that, even with moderate degrees of hepatic impairment, there is a decrease in clearance of drugs or active metabolites normally cleared by the kidney. The effect on renal clearance of unbound drug may be masked if there is a concomitant decrease in plasma protein binding of the drug. Neither serum creatinine levels nor creatinine clearance are useful markers of the renal dysfunction associated with cirrhosis. Both may greatly overestimate renal function in patients with cirrhosis due to increased fractional renal tubular secretion of creatinine. Altered receptor sensitivity has been observed with some drugs in cirrhosis, while for other drugs there is no change in pharmacodynamics. Precise determination of drug dosage in cirrhosis requires information on changes in pharmacodynamics and plasma protein binding in addition to changes in drug elimination. Pharmacokinetic investigations in a variety of chronic liver diseases without cirrhosis (e.g. carcinoma, schistosomiasis and viral hepatitis) suggest that in the absence of cirrhosis, impairment of drug elimination is not sufficient to warrant reduction of drug dosage. However, if cirrhosis is present, 'safe' drug use requires an awareness of the possibility of multiple interactions between changes in hepatic and renal disposition and pharmacodynamics. In chronic liver disease with cirrhosis, dosage reduction is the general rule regardless of the route of elimination of drug or metabolite.
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Affiliation(s)
- D J Morgan
- Department of Pharmaceutics, Victorian College of Pharmacy, Monash University, Melbourne, Australia
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