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Habiballah S, Reisfeld B. Adapting physiologically-based pharmacokinetic models for machine learning applications. Sci Rep 2023; 13:14934. [PMID: 37696914 PMCID: PMC10495394 DOI: 10.1038/s41598-023-42165-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 09/06/2023] [Indexed: 09/13/2023] Open
Abstract
Both machine learning and physiologically-based pharmacokinetic models are becoming essential components of the drug development process. Integrating the predictive capabilities of physiologically-based pharmacokinetic (PBPK) models within machine learning (ML) pipelines could offer significant benefits in improving the accuracy and scope of drug screening and evaluation procedures. Here, we describe the development and testing of a self-contained machine learning module capable of faithfully recapitulating summary pharmacokinetic (PK) parameters produced by a full PBPK model, given a set of input drug-specific and regimen-specific information. Because of its widespread use in characterizing the disposition of orally administered drugs, the PBPK model chosen to demonstrate the methodology was an open-source implementation of a state-of-the-art compartmental and transit model called OpenCAT. The model was tested for drug formulations spanning a large range of solubility and absorption characteristics, and was evaluated for concordance against predictions of OpenCAT and relevant experimental data. In general, the values predicted by the ML models were within 20% of those of the PBPK model across the range of drug and formulation properties. However, summary PK parameter predictions from both the ML model and full PBPK model were occasionally poor with respect to those derived from experiments, suggesting deficiencies in the underlying PBPK model.
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Affiliation(s)
- Sohaib Habiballah
- Department of Chemical and Biological Engineering, Colorado State University, Fort Collins, CO, 80523-1301, USA
| | - Brad Reisfeld
- Department of Chemical and Biological Engineering, Colorado State University, Fort Collins, CO, 80523-1301, USA.
- School of Public Health, Colorado State University, Fort Collins, CO, 80523-1612, USA.
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2
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Maeda K, Hagimori S, Sugimoto M, Sakai Y, Nishikawa M. Simulation of the crosstalk between glucose and acetaminophen metabolism in a liver zonation model. Front Pharmacol 2022; 13:995597. [PMID: 36210818 PMCID: PMC9537759 DOI: 10.3389/fphar.2022.995597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
The liver metabolizes a variety of substances that sometimes interact and regulate each other. The modeling of a single cell or a single metabolic pathway does not represent the complexity of the organ, including metabolic zonation (heterogeneity of functions) along with liver sinusoids. Here, we integrated multiple metabolic pathways into a single numerical liver zonation model, including drug and glucose metabolism. The model simulated the time-course of metabolite concentrations by the combination of dynamic simulation and metabolic flux analysis and successfully reproduced metabolic zonation and localized hepatotoxicity induced by acetaminophen (APAP). Drug metabolism was affected by nutritional status as the glucuronidation reaction rate changed. Moreover, sensitivity analysis suggested that the reported metabolic characteristics of obese adults and healthy infants in glucose metabolism could be associated with the metabolic features of those in drug metabolism. High activities of phosphoenolpyruvate carboxykinase (PEPCK) and glucose-6-phosphate phosphatase in obese adults led to increased APAP oxidation by cytochrome P450 2E1. In contrast, the high activity of glycogen synthase and low activities of PEPCK and glycogen phosphorylase in healthy infants led to low glucuronidation and high sulfation rates of APAP. In summary, this model showed the effects of glucose metabolism on drug metabolism by integrating multiple pathways into a single liver metabolic zonation model.
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Affiliation(s)
- Kazuhiro Maeda
- Department of Bioscience and Bioinformatics, Kyushu Institute of Technology, Iizuka, Fukuoka, Japan
| | - Shuta Hagimori
- Department of Chemical System Engineering, University of Tokyo, Tokyo, Japan
| | - Masahiro Sugimoto
- Institute of Medical Science, Tokyo Medical University, Tokyo, Japan
- Institute for Advanced Biosciences, Keio University, Yamagata, Japan
- *Correspondence: Masahiro Sugimoto,
| | - Yasuyuki Sakai
- Department of Chemical System Engineering, University of Tokyo, Tokyo, Japan
| | - Masaki Nishikawa
- Department of Chemical System Engineering, University of Tokyo, Tokyo, Japan
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3
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Unraveling the effect of intra- and intercellular processes on acetaminophen-induced liver injury. NPJ Syst Biol Appl 2022; 8:27. [PMID: 35933513 PMCID: PMC9357019 DOI: 10.1038/s41540-022-00238-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 07/20/2022] [Indexed: 11/09/2022] Open
Abstract
In high dosages, acetaminophen (APAP) can cause severe liver damage, but susceptibility to liver failure varies across individuals and is influenced by factors such as health status. Because APAP-induced liver injury and recovery is regulated by an intricate system of intra- and extracellular molecular signaling, we here aim to quantify the importance of specific modules in determining the outcome after an APAP insult and of potential targets for therapies that mitigate adversity. For this purpose, we integrated hepatocellular acetaminophen metabolism, DNA damage response induction and cell fate into a multiscale mechanistic liver lobule model which involves various cell types, such as hepatocytes, residential Kupffer cells and macrophages. Our model simulations show that zonal differences in metabolism and detoxification efficiency are essential determinants of necrotic damage. Moreover, the extent of senescence, which is regulated by intracellular processes and triggered by extracellular signaling, influences the potential to recover. In silico therapies at early and late time points after APAP insult indicated that prevention of necrotic damage is most beneficial for recovery, whereas interference with regulation of senescence promotes regeneration in a less pronounced way.
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Li J, Chiew AL, Isbister GK, Duffull SB. Population pharmacokinetics of immediate-release and modified-release paracetamol and its major metabolites in a supratherapeutic dosing study. Clin Toxicol (Phila) 2021; 60:25-32. [PMID: 34080498 DOI: 10.1080/15563650.2021.1928163] [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] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Overdose with paracetamol modified-release (MR) formulation, a bilayer tablet containing 69% slow-release component, has been increasing since its introduction to the market. However, little evidence exists for the management of MR paracetamol overdose. We aimed to develop a population pharmacokinetic (PK) model for immediate-release (IR) and MR paracetamol and its major metabolism, and quantitatively understand the formulation difference in toxicity assessment based on the nomogram line. METHODS Data from a cross-over study design in nine healthy volunteers administered a single supratherapeutic oral dose (80 mg/kg) of either IR and MR paracetamol were available from a published study. Plasma concentrations for paracetamol and its metabolites glucuronide (APAPG) and sulfate conjugate (APAPS) for both formulations were measured and analysed with population pharmacokinetic (PK) method using NONMEM. Toxicity in both formulations was assessed by comparing the simulated paracetamol concentrations under different paracetamol dose levels with the 150 mg/L nomograms. The difference in the assessment was compared between the two formulations. RESULTS Paracetamol concentrations for the IR formulation were described with a two-compartment model with first-order input and a lag time. The delayed time-course of MR paracetamol concentrations was best captured by a parallel absorption model in which the slow-release component was a serial zero-order then the first-order process. The formation of APAPG was linear, while APAPS concentrations were best fitted by a Michaelis-Menten process. The relative bioavailability of MR paracetamol compared to IR (FMR/IR) was estimated as 0.81. The simulated probability of making different toxicity assessments based on nomogram line was increased with dose levels and was as high as 14.6% after 22 g IR or MR paracetamol ingested. CONCLUSIONS A joint parent-metabolite model to describe time-course profiles of both IR and MR paracetamol and its metabolites APAPG and APAPS concentrations was developed. Simulations from the model showed that toxicity assessment based on the 150 mg/L nomograms is not suitable in MR paracetamol overdoses.
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Affiliation(s)
- Jingyun Li
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Angela L Chiew
- Emergency Department and Clinical Toxicology, Prince of Wales Hospital and Community Health Services, Randwick, Australia.,NSW Poisons Information Centre, Children's Hospital at Westmead, Westmead, Australia
| | - Geoffrey K Isbister
- NSW Poisons Information Centre, Children's Hospital at Westmead, Westmead, Australia.,Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
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Ghosh A, Berger I, Remien CH, Mubayi A. The role of alcohol consumption on acetaminophen induced liver injury: Implications from a mathematical model. J Theor Biol 2020; 519:110559. [PMID: 33333080 DOI: 10.1016/j.jtbi.2020.110559] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/02/2020] [Accepted: 12/02/2020] [Indexed: 01/13/2023]
Abstract
Acetaminophen (APAP) overdose is one of the predominant causes of drug induced acute liver injury in the U.S and U.K. Clinical studies show that ingestion of alcohol may increase the risk of APAP induced liver injury. Chronic alcoholism may potentiate APAP hepatotoxicity and this increased risk of APAP toxicity is observed when APAP is ingested even shortly after alcohol is cleared from the body. However, clinical reports also suggest that acute alcohol consumption may have a protective effect against hepatotoxicity by inhibiting microsomal acetaminophen oxidation and thereby reducing N-acetyl-p-benzoquinone imine (NAPQI) production. The aim of this study is to model this dual role of alcohol to determine how the timing of alcohol ingestion affects APAP metabolism and resulting liver injury and identify mechanisms of APAP induced liver injury. The mathematical model is developed to capture condition of a patient of single time APAP overdose who may be an acute or chronic alcohol user. The analysis suggests that the risk of APAP-induced hepatotoxicity is increased if APAP is ingested shortly after alcohol is cleared from the body in chronic alcohol users. A protective effect of acute consumption of alcohol is also observed in patients with APAP overdose. For example, simultaneous ingestion of alcohol and APAP overdose or alcohol intake after or before few hours of APAP overdose may result in less APAP-induced hepatotoxicity when compared to a single time APAP overdose. The rate of hepatocyte damage in APAP overdose patients depends on trade-off between induction and inhibition of CYP enzyme.
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Affiliation(s)
- Aditi Ghosh
- Mathematics Department, University of Wisconsin - Whitewater, Whitewater, WI 53190, USA.
| | - Isaac Berger
- Mathematics Department, Arizona State University, Tempe, AZ 53190, USA
| | | | - Anuj Mubayi
- PRECESIONheor, Los Angeles, CA, USA, Center for Collaborative Studies in Mathematical Biology, Illinois State University, Normal, IL, College of Health Solutions, Arizona State University, Tempe, AZ, USA
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Zhang S, Zhang E, Ho H. Extrapolation for a pharmacokinetic model for acetaminophen from adults to neonates: A Latin Hypercube Sampling analysis. Drug Metab Pharmacokinet 2020; 35:329-333. [PMID: 32307228 DOI: 10.1016/j.dmpk.2020.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 02/24/2020] [Accepted: 03/24/2020] [Indexed: 02/02/2023]
Abstract
Physiological and drug-specific parameters need to be adjusted when extrapolating a pharmacokinetic (PK) model from adults to neonates, so as to reproduce the time profiles of the studied drug(s) consistent with clinical, in vivo data or in vitro cell line measurements. In this paper we present a parameter analysis method, i.e. the Latin Hypercube Sampling (LHS) method for an acetaminophen (APAP) PK model. The original model consists of two compartments (the blood and the urine) with Michaelis-Menten kinetic parameters determined for APAP and its metabolites. The physiological parameters are scaled through allometric laws from adults to neonates, and APAP-specific parameters are adjusted for enzymatic maturational changes. The LHS method is used to statistically investigate the interplay between these parameters. The results for the extrapolated APAP model are consistent with published APAP PK data in neonates. We found the sulphation clearance parameter played a crucial role in the neonatal PK model, but its influence was weakened if the volume of distribution parameters were included. We suggest that this kind of in silico experiment could be valuable as the first step in PK model extrapolation between different ages.
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Affiliation(s)
- S Zhang
- Auckland Bioengineering Institute, The University of Auckland, Auckland, 1010, New Zealand
| | - E Zhang
- Chongqing Institute for Food and Drug Control, Chongqing City, China
| | - H Ho
- Auckland Bioengineering Institute, The University of Auckland, Auckland, 1010, New Zealand.
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7
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Hyndman L, McKee S, Mottram NJ, Singh B, Webb SD, McGinty S. Mathematical modelling of fluid flow and solute transport to define operating parameters for in vitro perfusion cell culture systems. Interface Focus 2020; 10:20190045. [PMID: 32194930 PMCID: PMC7061945 DOI: 10.1098/rsfs.2019.0045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 11/14/2019] [Indexed: 01/20/2023] Open
Abstract
In recent years, there has been a move away from the use of static in vitro two-dimensional cell culture models for testing the chemical safety and efficacy of drugs. Such models are increasingly being replaced by more physiologically relevant cell culture systems featuring dynamic flow and/or three-dimensional structures of cells. While it is acknowledged that such systems provide a more realistic environment within which to test drugs, progress is being hindered by a lack of understanding of the physical and chemical environment that the cells are exposed to. Mathematical and computational modelling may be exploited in this regard to unravel the dependency of the cell response on spatio-temporal differences in chemical and mechanical cues, thereby assisting with the understanding and design of these systems. In this paper, we present a mathematical modelling framework that characterizes the fluid flow and solute transport in perfusion bioreactors featuring an inlet and an outlet. To demonstrate the utility of our model, we simulated the fluid dynamics and solute concentration profiles for a variety of different flow rates, inlet solute concentrations and cell types within a specific commercial bioreactor chamber. Our subsequent analysis has elucidated the basic relationship between inlet flow rate and cell surface flow speed, shear stress and solute concentrations, allowing us to derive simple but useful relationships that enable prediction of the behaviour of the system under a variety of experimental conditions, prior to experimentation. We describe how the model may used by experimentalists to define operating parameters for their particular perfusion cell culture systems and highlight some operating conditions that should be avoided. Finally, we critically comment on the limitations of mathematical and computational modelling in this field, and the challenges associated with the adoption of such methods.
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Affiliation(s)
- Lauren Hyndman
- Division of Biomedical Engineering, University of Glasgow, Glasgow G12 8QQ, UK
| | - Sean McKee
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow G1 1XH, UK
| | - Nigel J. Mottram
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow G1 1XH, UK
| | - Bhumika Singh
- Kirkstall Ltd, York House, Outgang Lane, Osbaldwick, York YO19 5UP, UK
| | - Steven D. Webb
- Department of Applied Mathematics, Liverpool John Moores University, Liverpool L3 5UA, UK
| | - Sean McGinty
- Division of Biomedical Engineering, University of Glasgow, Glasgow G12 8QQ, UK
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8
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Lecoeur M, Rabenirina G, Schifano N, Odou P, Ethgen S, Lebuffe G, Foulon C. Determination of acetaminophen and its main metabolites in urine by capillary electrophoresis hyphenated to mass spectrometry. Talanta 2019; 205:120108. [DOI: 10.1016/j.talanta.2019.07.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/27/2019] [Accepted: 07/01/2019] [Indexed: 11/27/2022]
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Franiatte S, Clarke R, Ho H. A computational model for hepatotoxicity by coupling drug transport and acetaminophen metabolism equations. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2019; 35:e3234. [PMID: 31254976 DOI: 10.1002/cnm.3234] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/02/2019] [Accepted: 06/25/2019] [Indexed: 06/09/2023]
Abstract
The spatial distributions of cytochrome P450 (CYP450) and glutathione (GSH) in liver lobules determine the heterogeneous hepatotoxicity of acetaminophen (APAP). Their interplay in conjunction with blood flow is not well understood. In this paper, we integrate a cellular APAP metabolism model with a sinusoidal blood flow to simulate the temporal-spatial patterns of APAP-induced hepatotoxicity. The heterogeneous distribution of CYP450 and GSH is modeled by linearly varying their reaction rates along the portal triad to the central vein axis of a sinusoid. We found that the spatial distribution of GSH, glutathione S-transferases (GSTs), and CYP450 all contributes to the high acetaminophen protein adduct formation at zone 3 of the lobules. The reversed spatial gradients of CYP450 and GSH cause quick depletion of GSH, which is further accelerated by the distribution of GST. The hepatic flow congestion and hyperperfusion however do not seem to play a significant role in the zonal hepatotoxicity. The simulation results may be useful for understanding the APAP-induced hepatotoxicity and associated pharmaceutical treatment.
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Affiliation(s)
- Sylvain Franiatte
- ENSEEIHT, National Polytechnic Institute of Toulouse, Toulouse, France
| | - Richard Clarke
- Department of Engineering Science, The University of Auckland, Auckland, New Zealand
| | - Harvey Ho
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
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10
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Van Wijk RC, Krekels EHJ, Kantae V, Ordas A, Kreling T, Harms AC, Hankemeier T, Spaink HP, van der Graaf PH. Mechanistic and Quantitative Understanding of Pharmacokinetics in Zebrafish Larvae through Nanoscale Blood Sampling and Metabolite Modeling of Paracetamol. J Pharmacol Exp Ther 2019; 371:15-24. [PMID: 31371482 DOI: 10.1124/jpet.119.260299] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/31/2019] [Indexed: 12/27/2022] Open
Abstract
Zebrafish larvae are increasingly used for pharmacological research, but internal drug exposure is often not measured. Understanding pharmacokinetics is necessary for reliable translation of pharmacological results to higher vertebrates, including humans. Quantification of drug clearance and distribution requires measurements of blood concentrations. Additionally, measuring drug metabolites is of importance to understand clearance in this model organism mechanistically. We therefore mechanistically studied and quantified pharmacokinetics in zebrafish larvae, and compared this to higher vertebrates, using paracetamol (acetaminophen) as a paradigm compound. A method was developed to sample blood from zebrafish larvae 5 days post fertilization. Blood concentrations of paracetamol and its major metabolites, paracetamol-glucuronide and paracetamol-sulfate, were measured. Blood concentration data were combined with measured amounts in larval homogenates and excreted amounts and simultaneously analyzed through nonlinear mixed-effects modeling, quantifying absolute clearance and distribution volume. Blood sampling from zebrafish larvae was most successful from the posterior cardinal vein, with a median volume (interquartile range) of 1.12 nl (0.676-1.66 nl) per blood sample. Samples were pooled (n = 15-35) to reach measurable levels. Paracetamol blood concentrations at steady state were only 10% of the external paracetamol concentration. Paracetamol-sulfate was the major metabolite, and its formation was quantified using a time-dependent metabolic formation rate. Absolute clearance and distribution volume correlated well with reported values in higher vertebrates, including humans. Based on blood concentrations and advanced data analysis, the mechanistic and quantitative understanding of paracetamol pharmacokinetics in zebrafish larvae has been established. This will improve the translational value of this vertebrate model organism in drug discovery and development. SIGNIFICANCE STATEMENT: In early phases of drug development, new compounds are increasingly screened in zebrafish larvae, but the internal drug exposure is often not taken into consideration. We developed innovative experimental and computational methods, including a blood-sampling technique, to measure the paradigm drug paracetamol (acetaminophen) and its major metabolites and quantify pharmacokinetics (absorption, distribution, elimination) in zebrafish larvae of 5 days post fertilization with a total volume of only 300 nl. These parameter values were scaled to higher vertebrates, including humans.
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Affiliation(s)
- Rob C Van Wijk
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (R.C.v.W., E.H.J.K., V.K., T.K., A.C.H., T.H., P.H.v.d.G.) and Animal Sciences and Health, Institute of Biology Leiden (A.O., H.P.S.), Leiden University, Leiden, The Netherlands; and Certara QSP, Canterbury, United Kingdom (P.H.v.d.G.)
| | - Elke H J Krekels
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (R.C.v.W., E.H.J.K., V.K., T.K., A.C.H., T.H., P.H.v.d.G.) and Animal Sciences and Health, Institute of Biology Leiden (A.O., H.P.S.), Leiden University, Leiden, The Netherlands; and Certara QSP, Canterbury, United Kingdom (P.H.v.d.G.)
| | - Vasudev Kantae
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (R.C.v.W., E.H.J.K., V.K., T.K., A.C.H., T.H., P.H.v.d.G.) and Animal Sciences and Health, Institute of Biology Leiden (A.O., H.P.S.), Leiden University, Leiden, The Netherlands; and Certara QSP, Canterbury, United Kingdom (P.H.v.d.G.)
| | - Anita Ordas
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (R.C.v.W., E.H.J.K., V.K., T.K., A.C.H., T.H., P.H.v.d.G.) and Animal Sciences and Health, Institute of Biology Leiden (A.O., H.P.S.), Leiden University, Leiden, The Netherlands; and Certara QSP, Canterbury, United Kingdom (P.H.v.d.G.)
| | - Thijs Kreling
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (R.C.v.W., E.H.J.K., V.K., T.K., A.C.H., T.H., P.H.v.d.G.) and Animal Sciences and Health, Institute of Biology Leiden (A.O., H.P.S.), Leiden University, Leiden, The Netherlands; and Certara QSP, Canterbury, United Kingdom (P.H.v.d.G.)
| | - Amy C Harms
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (R.C.v.W., E.H.J.K., V.K., T.K., A.C.H., T.H., P.H.v.d.G.) and Animal Sciences and Health, Institute of Biology Leiden (A.O., H.P.S.), Leiden University, Leiden, The Netherlands; and Certara QSP, Canterbury, United Kingdom (P.H.v.d.G.)
| | - Thomas Hankemeier
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (R.C.v.W., E.H.J.K., V.K., T.K., A.C.H., T.H., P.H.v.d.G.) and Animal Sciences and Health, Institute of Biology Leiden (A.O., H.P.S.), Leiden University, Leiden, The Netherlands; and Certara QSP, Canterbury, United Kingdom (P.H.v.d.G.)
| | - Herman P Spaink
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (R.C.v.W., E.H.J.K., V.K., T.K., A.C.H., T.H., P.H.v.d.G.) and Animal Sciences and Health, Institute of Biology Leiden (A.O., H.P.S.), Leiden University, Leiden, The Netherlands; and Certara QSP, Canterbury, United Kingdom (P.H.v.d.G.)
| | - Piet H van der Graaf
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (R.C.v.W., E.H.J.K., V.K., T.K., A.C.H., T.H., P.H.v.d.G.) and Animal Sciences and Health, Institute of Biology Leiden (A.O., H.P.S.), Leiden University, Leiden, The Netherlands; and Certara QSP, Canterbury, United Kingdom (P.H.v.d.G.)
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Sorrell I, Shipley RJ, Regan S, Gardner I, Storm MP, Ellis M, Ward J, Williams D, Mistry P, Salazar JD, Scott A, Webb S. Mathematical modelling of a liver hollow fibre bioreactor. J Theor Biol 2019; 475:25-33. [DOI: 10.1016/j.jtbi.2019.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 04/30/2019] [Accepted: 05/13/2019] [Indexed: 12/18/2022]
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12
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Impact of post-hatching maturation on the pharmacokinetics of paracetamol in zebrafish larvae. Sci Rep 2019; 9:2149. [PMID: 30770889 PMCID: PMC6377609 DOI: 10.1038/s41598-019-38530-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/18/2018] [Indexed: 01/13/2023] Open
Abstract
Zebrafish larvae are increasingly used in pharmacological and toxicological studies, but it is often overlooked that internal exposure to exogenous compounds, rather than the incubation medium concentration, is driving observed effects. Moreover, as the zebrafish larva is a developing organism, continuous physiological changes impact pharmacokinetic or toxicokinetic processes like the absorption and elimination of exogenous compounds, influencing the interpretation of observations and conclusions drawn from experiments at different larval ages. Here, using paracetamol as paradigm compound, mathematical modelling is used to quantify absorption and elimination rates from internal exposure over time profiles after waterborne treatment, as well as changes in these parameters in post-hatching larvae of 3, 4, and 5 days post fertilisation (dpf). An increase of 106% in absorption rate was observed between 3 and 4 dpf, but no further increase at 5 dpf, and an increase of 17.5% in elimination rate for each dpf. Paracetamol clearance, determined from elimination rate constants and reported total larval volumes of 253, 263, and 300 nL at 3, 4, and 5 dpf respectively, correlates best with higher vertebrates at 5 dpf. This suggests that when studying direct effects of exogenous compounds, experiments with zebrafish larvae are best performed at 5 dpf.
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Means SA, Ho H. A spatial-temporal model for zonal hepatotoxicity of acetaminophen. Drug Metab Pharmacokinet 2018; 34:71-77. [PMID: 30377056 DOI: 10.1016/j.dmpk.2018.09.266] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 09/11/2018] [Accepted: 09/28/2018] [Indexed: 12/19/2022]
Abstract
The metabolism zonation in liver lobules is well known yet its incorporation into the mathematical models of acetaminophen (APAP) metabolism is still primitive - only the oxidation pathway via reaction with the cytochrome P450 (CYP450) has been considered, yet the zonal heterogeneity exhibits in all three pathways including sulphation, glucuronidation and oxidation. In this paper we present a novel computational method where an intracellular APAP metabolism model is integrated into a Finite Element Model (FEM) of sinusoids, and the zonal heterogeneity in three metabolism pathways are all incorporated. We demonstrate that the degradation of APAP, detoxification via glutathione (GSH) and the formation of hepatotoxicity, are all affected profoundly by the zonal difference. Specifically, glucuronidation plays a major role in the degradation of APAP. Generation of GSH, its conjugation with the toxic NAPQI and the spatial distribution of CYP450 combined together determine the toxicity of APAP. We suggest that the current platform be used for further hepatotoxicity study of APAP by incorporating other heterogeneity factors.
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Affiliation(s)
- Shawn A Means
- Auckland Bioengineering Institute, The University of Auckland, New Zealand
| | - Harvey Ho
- Auckland Bioengineering Institute, The University of Auckland, New Zealand.
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14
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Mason CL, Leedale J, Tasoulis S, Jarman I, Antoine DJ, Webb SD. Systems Toxicology Approach to Identifying Paracetamol Overdose. CPT Pharmacometrics Syst Pharmacol 2018; 7:394-403. [PMID: 29667370 PMCID: PMC6027737 DOI: 10.1002/psp4.12298] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 03/12/2018] [Accepted: 03/12/2018] [Indexed: 12/15/2022] Open
Abstract
Paracetamol (acetaminophen (APAP)) is one of the most commonly used analgesics in the United Kingdom and the United States. However, exceeding the maximum recommended dose can cause serious liver injury and even death. Promising APAP toxicity biomarkers are thought to add value to those used currently and clarification of the functional relationships between these biomarkers and liver injury would aid clinical implementation of an improved APAP toxicity identification framework. The framework currently used to define an APAP overdose is highly dependent upon time since ingestion and initial dose; information that is often highly unpredictable. A pharmacokinetic/pharmacodynamic (PK/PD) APAP model has been built in order to understand the relationships between a panel of biomarkers and APAP dose. Visualization and statistical tools have been used to predict initial APAP dose and time since administration. Additionally, logistic regression analysis has been applied to histology data to provide a prediction of the probability of liver injury.
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Affiliation(s)
- Chantelle L. Mason
- Department of Applied MathematicsLiverpool John Moores UniversityLiverpoolUK
| | - Joseph Leedale
- EPSRC Liverpool Centre for Mathematics in Healthcare, Department of Mathematical SciencesUniversity of LiverpoolLiverpoolUK
| | - Sotiris Tasoulis
- Department of Applied MathematicsLiverpool John Moores UniversityLiverpoolUK
| | - Ian Jarman
- Department of Applied MathematicsLiverpool John Moores UniversityLiverpoolUK
| | - Daniel J. Antoine
- MRC Centre for Inflammation ResearchQueens Medical Research Institute, University of EdinburghEdinburghUK
| | - Steven D. Webb
- Department of Applied MathematicsLiverpool John Moores UniversityLiverpoolUK
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15
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Reith DM. Comment on: "Morbidly Obese Patients Exhibit Increased CYP2E1-Mediated Oxidation of Acetaminophen". Clin Pharmacokinet 2018; 57:895-896. [PMID: 29725998 DOI: 10.1007/s40262-018-0666-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- David M Reith
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
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16
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Gaohua L, Neuhoff S, Johnson TN, Rostami-Hodjegan A, Jamei M. Development of a permeability-limited model of the human brain and cerebrospinal fluid (CSF) to integrate known physiological and biological knowledge: Estimating time varying CSF drug concentrations and their variability using in vitro data. Drug Metab Pharmacokinet 2016; 31:224-33. [DOI: 10.1016/j.dmpk.2016.03.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 03/04/2016] [Accepted: 03/27/2016] [Indexed: 12/15/2022]
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17
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Timescale analysis of a mathematical model of acetaminophen metabolism and toxicity. J Theor Biol 2015; 386:132-46. [PMID: 26348886 DOI: 10.1016/j.jtbi.2015.08.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/03/2015] [Accepted: 08/26/2015] [Indexed: 01/13/2023]
Abstract
Acetaminophen is a widespread and commonly used painkiller all over the world. However, it can cause liver damage when taken in large doses or at repeated chronic doses. Current models of acetaminophen metabolism are complex, and limited to numerical investigation though provide results that represent clinical investigation well. We derive a mathematical model based on mass action laws aimed at capturing the main dynamics of acetaminophen metabolism, in particular the contrast between normal and overdose cases, whilst remaining simple enough for detailed mathematical analysis that can identify key parameters and quantify their role in liver toxicity. We use singular perturbation analysis to separate the different timescales describing the sequence of events in acetaminophen metabolism, systematically identifying which parameters dominate during each of the successive stages. Using this approach we determined, in terms of the model parameters, the critical dose between safe and overdose cases, timescales for exhaustion and regeneration of important cofactors for acetaminophen metabolism and total toxin accumulation as a fraction of initial dose.
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18
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Owens KH, Medlicott NJ, Zacharias M, Whyte IM, Buckley NA, Reith DM. Population pharmacokinetic-pharmacodynamic modelling to describe the effects of paracetamol and N-acetylcysteine on the international normalized ratio. Clin Exp Pharmacol Physiol 2014; 42:102-8. [DOI: 10.1111/1440-1681.12327] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 10/07/2014] [Accepted: 10/07/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Katie H Owens
- School of Pharmacy; University of Otago; Dunedin New Zealand
| | | | | | - Ian M Whyte
- Department of Clinical Toxicology; Calvary Mater Newcastle and School of Medicine and Public Health; University of Newcastle; Newcastle NSW Australia
| | - Nicholas A Buckley
- Pharmacology; Sydney Medical School; University of Sydney; Sydney NSW Australia
| | - David M Reith
- Dunedin School of Medicine; University of Otago; Dunedin New Zealand
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19
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Prot JM, Maciel L, Bricks T, Merlier F, Cotton J, Paullier P, Bois FY, Leclerc E. First pass intestinal and liver metabolism of paracetamol in a microfluidic platform coupled with a mathematical modeling as a means of evaluating ADME processes in humans. Biotechnol Bioeng 2014; 111:2027-40. [PMID: 24954399 DOI: 10.1002/bit.25232] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/05/2014] [Accepted: 03/06/2014] [Indexed: 11/07/2022]
Abstract
We developed a microfluidic platform to investigate paracetamol intestinal and liver first pass metabolism. This approach was coupled with a mathematical model to estimate intrinsic in vitro parameters and to predict in vivo processes. The kinetic modeling estimated the paracetamol and paracetamol sulfate permeabilities, the sulfate and glucuronide effluxes in the intestine compartment. Based on a gut model, we estimated intrinsic intestinal clearance of between 26 and 77 L/h for paracetamol in humans, a permeability of 10 L/h, and a gut availability between 0.17 and 0.53 (compared to 0.95-1 in vivo). The role played by the liver in paracetamol metabolism was estimated via in vitro intrinsic clearances of 7.6, 13.6, and 11.5 µL/min/10(6) cells for HepG2/C3a, rat primary hepatocytes, and human primary hepatocytes, respectively. Based on a parallel tube model to describe the liver, the paracetamol hepatic clearance, and the paracetamol hepatic availability in humans were estimated at 6.5 mL/min/kg of bodyweight (BDW) and 0.7, respectively (when compared to 5 mL/min/kg of BDW and 0.77 to 0.88 for in vivo values, respectively). The drug availability was predicted ranging between 0.24 and 0.41 (0.88 in vivo). The overall approach provided a first step in an integrated strategy combining in silico/in vitro methods based on microfluidic for evaluating drug absorption, distribution and metabolism processes.
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Affiliation(s)
- Jean Matthieu Prot
- CNRS UMR 7338, Laboratoire de Biomécanique et Bio ingénierie, Université de Technologie de Compiègne, Compiegne, Picardie, France
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20
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James MO, Ambadapadi S. Interactions of cytosolic sulfotransferases with xenobiotics. Drug Metab Rev 2014; 45:401-14. [PMID: 24188364 DOI: 10.3109/03602532.2013.835613] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Cytosolic sulfotransferases are a superfamily of enzymes that catalyze the transfer of the sulfonic group from 3'-phosphoadenosine-5'-phosphosulfate to hydroxy or amine groups in substrate molecules. The human cytosolic sulfotransferases that have been most studied, namely SULT1A1, SULT1A3, SULT1B1, SULT1E1 and SULT2A1, are expressed in different tissues of the body, including liver, intestine, adrenal, brain and skin. These sulfotransferases play important roles in the sulfonation of endogenous molecules such as steroid hormones and neurotransmitters, and in the elimination of xenobiotic molecules such as drugs, environmental chemicals and natural products. There is often overlapping substrate selectivity among the sulfotransferases, although one isoform may exhibit greater enzyme efficiency than other isoforms. Similarly, inhibitors or enhancers of one isoform often affect other isoforms, but typically with different potency. This means that if the activity of one form of sulfotransferase is altered (either inhibited or enhanced) by the presence of a xenobiotic, the sulfonation of endogenous and xenobiotic substrates for other isoforms may well be affected. There are more examples of inhibitors than enhancers of sulfonation. Modulators of sulfotransferase enzymes include natural products ingested as part of the human diet as well as environmental chemicals and drugs. This review will discuss recent work on such interactions.
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Affiliation(s)
- Margaret O James
- Department of Medicinal Chemistry, University of Florida, Gainesville , FL , USA
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21
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Owens KH, Murphy PGM, Medlicott NJ, Kennedy J, Zacharias M, Curran N, Sreebhavan S, Thompson-Fawcett M, Reith DM. Population pharmacokinetics of intravenous acetaminophen and its metabolites in major surgical patients. J Pharmacokinet Pharmacodyn 2014; 41:211-21. [DOI: 10.1007/s10928-014-9358-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 04/09/2014] [Indexed: 01/13/2023]
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22
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Navid A, Ng DM, Stewart BJ, Wong SE, Lightstone FC. Quantitative In Silico analysis of transient metabolism of acetaminophen and associated causes of hepatotoxicity in humans. In Silico Pharmacol 2013. [PMCID: PMC4750864 DOI: 10.1186/2193-9616-1-14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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23
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Bylda C, Thiele R, Kobold U, Volmer DA. Simultaneous quantification of acetaminophen and structurally related compounds in human serum and plasma. Drug Test Anal 2013; 6:451-60. [DOI: 10.1002/dta.1527] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 07/26/2013] [Accepted: 07/27/2013] [Indexed: 01/30/2023]
Affiliation(s)
| | | | - Uwe Kobold
- Roche Diagnostics GmbH; Penzberg; Germany
| | - Dietrich A. Volmer
- Institute of Bioanalytical Chemistry; Saarland University; Saarbrücken; Germany
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24
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The pharmacokinetic profile of intravenous paracetamol in adult patients undergoing major abdominal surgery. Ther Drug Monit 2013; 34:713-21. [PMID: 23149443 DOI: 10.1097/ftd.0b013e31826a70ea] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Intravenous (IV) paracetamol is commonly used in the postoperative period for the treatment of mild to moderate pain. The main pathways for paracetamol metabolism are glucuronidation, sulfation, and oxidation, accounting for approximately 55%, 30%, and 10% of urinary metabolites, respectively. The aim of this study was to describe the pharmacokinetics of IV paracetamol and its metabolites in adult patients after major abdominal surgery. METHODS Twenty patients were given 1 g of paracetamol by IV infusion at induction of anesthesia (Interval 1) and every 6 hours thereafter, with the final dose given at 48-72 hours (Interval 2). Plasma and urine samples were collected for up to 8 hours after infusion for both intervals. The samples were analyzed by high-performance liquid chromatography to determine the amount of paracetamol and its metabolites. The data were modeled in Phoenix WinNonlin using a user-defined ASCII parent-metabolite model with linear disposition, to obtain the estimates for volume of distribution, metabolic and urinary clearance. RESULTS Mean (95% confidence interval) metabolic clearance to paracetamol glucuronide increased from 0.06 (0.05-0.08) to 0.14 (0.11-0.18) L · h⁻¹ · kg⁻¹, P value <0.001 and urinary clearance increased from 0.08 (0.07-0.09) to 0.14 (0.10-0.17) L · h⁻¹ · kg⁻¹, P value 0.002. The mean (95% confidence interval) volume of distribution of paracetamol increased from 0.17 (0.12-0.21) to 0.43 (0.27-0.59) L · kg⁻¹, P value 0.032. CONCLUSIONS After major abdominal surgery, there were apparent increases in the metabolic conversion to paracetamol glucuronide and its urinary clearance suggesting potential induction of paracetamol glucuronidation.
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25
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Ganetsky M, Böhlke M, Pereira L, Williams D, LeDuc B, Guatam S, Salhanick SD. Effect of excipients on acetaminophen metabolism and its implications for prevention of liver injury. J Clin Pharmacol 2013; 53:413-20. [PMID: 23436315 DOI: 10.1002/jcph.24] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 08/09/2012] [Indexed: 12/20/2022]
Abstract
Acetaminophen poisoning is the most frequent cause of acute hepatic failure in the US. Toxicity requires reductive metabolism of acetaminophen, primarily via CYP2E1. Liquid acetaminophen preparations contain propylene glycol, a common excipient that has been shown to reduce hepatocellular injury in vitro and in rodents. Children are less susceptible to acetaminophen toxicity for unclear reasons. We conducted a pharmacokinetic single-blinded crossover study of 15 healthy adult volunteers comparing the CYP2E1 and conjugative metabolism of a 15 mg/kg dose of liquid versus solid preparations of acetaminophen. Measured AUC's for the CYP2E1 metabolites were 16-17% lower and extrapolated AUC's were 25-28% lower in the liquid formulation arm while there was no difference in conjugative metabolite production. The formation rate constants for reductive metabolites were equivalent between solid and liquid formulations indicating that enzyme inhibition was competitive. Propylene glycol, an established CYP2E1 competitive antagonist, was detected in the liquid formulation but not solid formulation arm. Since children tend to ingest liquid preparations, the protective effect of this excipient could explain their decreased susceptibility to acetaminophen toxicity. A less hepatotoxic formulation of acetaminophen could potentially be developed if co-formulated with a CYP2E1 inhibitor.
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Affiliation(s)
- Michael Ganetsky
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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26
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Ben-Shachar R, Chen Y, Luo S, Hartman C, Reed M, Nijhout HF. The biochemistry of acetaminophen hepatotoxicity and rescue: a mathematical model. Theor Biol Med Model 2012; 9:55. [PMID: 23249634 PMCID: PMC3576299 DOI: 10.1186/1742-4682-9-55] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 12/04/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acetaminophen (N-acetyl-para-aminophenol) is the most widely used over-the-counter or prescription painkiller in the world. Acetaminophen is metabolized in the liver where a toxic byproduct is produced that can be removed by conjugation with glutathione. Acetaminophen overdoses, either accidental or intentional, are the leading cause of acute liver failure in the United States, accounting for 56,000 emergency room visits per year. The standard treatment for overdose is N-acetyl-cysteine (NAC), which is given to stimulate the production of glutathione. METHODS We have created a mathematical model for acetaminophen transport and metabolism including the following compartments: gut, plasma, liver, tissue, urine. In the liver compartment the metabolism of acetaminophen includes sulfation, glucoronidation, conjugation with glutathione, production of the toxic metabolite, and liver damage, taking biochemical parameters from the literature whenever possible. This model is then connected to a previously constructed model of glutathione metabolism. RESULTS We show that our model accurately reproduces published clinical and experimental data on the dose-dependent time course of acetaminophen in the plasma, the accumulation of acetaminophen and its metabolites in the urine, and the depletion of glutathione caused by conjugation with the toxic product. We use the model to study the extent of liver damage caused by overdoses or by chronic use of therapeutic doses, and the effects of polymorphisms in glucoronidation enzymes. We use the model to study the depletion of glutathione and the effect of the size and timing of N-acetyl-cysteine doses given as an antidote. Our model accurately predicts patient death or recovery depending on size of APAP overdose and time of treatment. CONCLUSIONS The mathematical model provides a new tool for studying the effects of various doses of acetaminophen on the liver metabolism of acetaminophen and glutathione. It can be used to study how the metabolism of acetaminophen depends on the expression level of liver enzymes. Finally, it can be used to predict patient metabolic and physiological responses to APAP doses and different NAC dosing strategies.
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Affiliation(s)
- Rotem Ben-Shachar
- Program in Computational Biology and Bioinformatics, Duke University, Durham, NC, USA
| | - Yifei Chen
- Program in Biophysics, Duke University, Durham, NC, USA
| | - Shishi Luo
- Department of Mathematics, Duke University, Durham, NC, USA
| | | | - Michael Reed
- Department of Mathematics, Duke University, Durham, NC, USA
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27
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Abstract
An intravenous formulation of acetaminophen was introduced to the United States in 2011. Experience from Europe indicates that serious dosing errors are likely to occur. Most events have involved a 10-fold dosing error in small children caused by calculating the dosage in milligrams, but then administering the solution in milliliters. The solution is 10 mg/mL; therefore, a 10-fold overdose occurs. Evaluation of overdose with the intravenous formulation is similar to oral overdose. A serum acetaminophen concentration should be drawn 4 hours after the infusion was started or as soon thereafter as possible. If the serum acetaminophen concentration plots above the treatment line on the Rumack-Matthew nomogram, treatment with acetylcysteine should be initiated. Health care providers are encouraged to contact their regional poison center (1-800-222-1222) so that dosing errors will be reported, and the experience with this new product can be accumulated.
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Affiliation(s)
- Richard C Dart
- Denver Health Medical Center, Rocky Mountain Poison and Drug Center, Denver, CO 80204, USA.
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