Clinical pharmacokinetics of cerebrospinal fluid

Cerebrospinal fluid concentrations of fluoroquinolones and carbapenems in tuberculosis meningitis

Background: Tuberculosis meningitis (TBM) is the most lethal form of TB. It is difficult to treat in part due to poor or uncertain drug penetration into the central nervous system (CNS). To help fill this knowledge gap, we evaluated the cerebrospinal fluid (CSF) concentrations of fluoroquinolones and carbapenems in patients being treated for TBM. Methods: Serial serum and CSF samples were collected from hospitalized patients being treated for TBM. CSF was collected from routine lumbar punctures between alternating timepoints of 2 and 6 h after drug administration to capture early and late CSF penetration. Rich serum sampling was collected after drug administration on day 28 for non-compartmental analysis. Results: Among 22 patients treated for TBM (8 with confirmed disease), there was high use of fluoroquinolones (levofloxacin, 21; moxifloxacin, 10; ofloxacin, 6) and carbapenems (imipenem, 11; meropenem, 6). Median CSF total concentrations of levofloxacin at 2 and 6 h were 1.34 mg/L and 3.36 mg/L with adjusted CSF/serum ratios of 0.41 and 0.63, respectively. For moxifloxacin, the median CSF total concentrations at 2 and 6 h were 0.78 mg/L and 1.02 mg/L with adjusted CSF/serum ratios of 0.44 and 0.62. Serum and CSF concentrations of moxifloxacin were not affected by rifampin use. Among the 76 CSF samples measured for carbapenem concentrations, 79% were undetectable or below the limit of detection. Conclusion: Fluoroquinolones demonstrated high CSF penetration indicating their potential usefulness for the treatment of TBM. Carbapenems had lower than expected CSF concentrations.

Multiple-Dose Plasma Pharmacokinetic and Safety Study of LY450108 and LY451395 (AMPA Receptor Potentiators) and Their Concentration in Cerebrospinal Fluid in Healthy Human Subjects

The objective of this study was to measure the steady-state cerebrospinal fluid (CSF) concentration of LY450108 and LY451395 (positive modulators of AMPA receptors) in healthy subjects after the administration of 1 mg and 5 mg. Secondary objectives included the evaluation of safety, pharmacokinetics, and steady-state ratio of plasma:CSF concentrations of LY450108 and LY451395 after multiple dosing. This study was an open-label, multiple oral dose study evaluating 1 mg and 5 mg LY450108 and 1 mg and 5 mg LY451395 in 12 (3 subjects per dosing group) healthy subjects, aged 18 to 49 years. Twelve healthy male subjects completed the study. LY450108 and LY451395 were quantifiable in CSF after 1-mg and 5-mg multiple-dose administrations with plasma:CSF ratio of 82:1 and 44:1, respectively. LY450108 and LY451395 1 mg and 5 mg were measured in the CSF. Single and multiple oral doses of LY450108 and LY451395 were determined to be safe and well tolerated in healthy subjects.

Utility of CSF in translational neuroscience

Human cerebrospinal fluid (CSF) sampling is of high value as the only general applicable methodology to obtain information on free drug concentrations in individual human brain. As the ultimate interest is in the free drug concentration at the CNS target site, the question is what CSF concentrations may tell us in that respect. Studies have been performed in rats and other animals for which concentrations in brain extracellular fluid (brain ECF) as a target site for many drugs, have been compared to (cisterna magna) CSF concentrations, at presumed steady state conditions,. The data indicated that CSF drug concentrations provided a rather good indication of, but not a reliable measure for predicting brain ECF concentrations. Furthermore, comparing rat with human CSF concentrations, human CSF concentrations tend to be higher and display much more variability. However, this comparison of CSF concentrations cannot be a direct one, as humans probably had a disease for which CSF was collected in the first place, while the rats were healthy. In order to be able to more accurately predict human brain ECF concentrations, understanding of the complexity of the CNS in terms of intrabrain pharmacokinetic relationships and the influence of CNS disorders on brain pharmacokinetics needs to be increased. This can be achieved by expanding a currently existing preclinically derived physiologically based pharmacokinetic model for brain distribution. This model has been shown to successfully predict data obtained for human lumbar CSF concentrations of acetaminophen which renders trust in the model prediction of human brain ECF concentrations. This model should further evolute by inclusion of influences of drug properties, fluid flows, transporter functionalities and different disease conditions. Finally the model should include measures of target site engagement and CNS effects, to ultimately learn about concentrations that best predict particular target site concentrations, via human CSF concentrations.

Challenges for blood-brain barrier (BBB) screening

Whilst blood-brain barrier permeability is an important determinant in achieving efficacious central nervous system drug concentrations, it should not be viewed or measured in isolation. Recent studies have highlighted the need for an integrated approach where optimal central nervous system penetration is achieved through the correct balance of permeability, a low potential for active efflux, and the appropriate physicochemical properties that allow for drug partitioning and distribution into brain tissue. Integrating data from permeability studies performed incorporating an assessment of active efflux by P-glycoprotein in combination with drug-free fraction measurements in blood and brain has furthered the understanding of the impact of the blood-brain barrier on central nervous system uptake and the underlying physicochemical properties that contribute to central nervous system drug disposition. This approach moves away from screening and ranking compounds in assays designed to measure or predict central nervous system penetration in the somewhat arbitrary units of brain-blood (or plasma) ratios.

Evaluation of cerebrospinal fluid concentration and plasma free concentration as a surrogate measurement for brain free concentration

This study was designed to evaluate the use of cerebrospinal fluid (CSF) drug concentration and plasma unbound concentration (C(u,plasma)) to predict brain unbound concentration (C(u,brain)). The concentration-time profiles in CSF, plasma, and brain of seven model compounds were determined after subcutaneous administration in rats. The C(u,brain) was estimated from the product of total brain concentrations and unbound fractions, which were determined using brain tissue slice and brain homogenate methods. For theobromine, theophylline, caffeine, fluoxetine, and propranolol, which represent rapid brain penetration compounds with a simple diffusion mechanism, the ratios of the area under the curve of C(u,brain)/C(CSF) and C(u,brain)/C(u,plasma) were 0.27 to 1.5 and 0.29 to 2.1, respectively, using the brain slice method, and were 0.27 to 2.9 and 0.36 to 3.9, respectively, using the brain homogenate method. A P-glycoprotein substrate, CP-141938 (methoxy-3-[(2-phenyl-piperadinyl-3-amino)-methyl]-phenyl-N-methyl-methane-sulfonamide), had C(u,brain)/C(CSF) and C(u,brain)/C(u,plasma) ratios of 0.57 and 0.066, using the brain slice method, and 1.1 and 0.13, using the brain homogenate method, respectively. The slow brain-penetrating compound, N[3-(4'-fluorophenyl)-3-(4'-phenylphenoxy)propyl-]sarcosine, had C(u,brain)/C(CSF) and C(u,brain)/C(u,plasma) ratios of 0.94 and 0.12 using the brain slice method and 0.15 and 0.018 using the brain homogenate method, respectively. Therefore, for quick brain penetration with simple diffusion mechanism compounds, C(CSF) and C(u,plasma) represent C(u,brain) equally well; for efflux substrates or slow brain penetration compounds, C(CSF) appears to be equivalent to or more accurate than C(u,plasma) to represent C(u,brain). Thus, we hypothesize that C(CSF) is equivalent to or better than C(u,plasma) to predict C(u,brain). This hypothesis is supported by the literature data.

Influence of a polymeric formulation of ketoprofen on its diffusion into cerebrospinal fluid in rats

Poly(D,L)lactide nanocapsules (NCs) have been proposed as an alternative carrier for many drugs. We investigated the influence of this formulation on the pharmacokinetics of ketoprofen in the plasma and cerebrospinal fluid (CSF). Male Wistar rats were given intraperitoneal dose of ketoprofen (5 mg/kg) in a suspension of NCs or in a carboxymethylcellulose (CMC) solution (reference preparation). Blood and CSF samples were collected at different times up to 24 h after dosing. The unbound fraction of ketoprofen in plasma (f(u)) was determined using ultrafiltration. The total (C(T)) and free (C(F)) concentrations of ketoprofen in plasma and the simultaneous CSF concentrations (C(CSF)) were measured by a HPLC method and the areas under the curve (AUC(T), AUC(F), AUC(CSF)) were calculated. AUC(T) of ketoprofen-loaded NCs in plasma was similar to that of the reference solution, while AUC(F) of the former (5.41 mg/l x h) was higher than that produced by the latter (4.03 mg/l x h). Accordingly, the unbound fraction (f(u)) was higher after administration of NCs than that of the solution (2.5 and 1.8%, respectively). Finally, AUC(CSF) were identical for both formulations. These findings suggest that the binding of ketoprofen to plasma proteins is not the major factor that governs its blood-to-CSF exchanges.

Usefulness of Saliva for Measurement of 3,4-Methylenedioxymethamphetamine and Its Metabolites: Correlation with Plasma Drug Concentrations and Effect of Salivary pH

Background: Saliva is an alternative biologic matrix for drugs-of-abuse testing that offers the advantages of noninvasive, rapid, and easy sampling. We studied the excretion profile of 3,4-methylenedioxymethamphetamine (MDMA) and its metabolites in both saliva and plasma, as well the effect of the drug on salivary pH.

Methods: Saliva and plasma samples were obtained from eight healthy MDMA consumers after ingestion of a single 100-mg dose of the drug. Concentrations of MDMA and its main metabolites, 3,4-methylenedioxyamphetamine (MDA) and 4-hydroxy-3-methoxymethamphetamine (HMMA), in saliva and plasma were measured by gas chromatography-mass spectrometry. Apparent pharmacokinetic parameters for MDMA in saliva were estimated, and the saliva-to-plasma ratio at each time interval was calculated and correlated with salivary pH.

Results: MDMA, MDA, and HMMA were detected in saliva. Salivary concentrations of MDMA were 1728.9–6510.6 μg/L and peaked at 1.5 h after drug intake. This was followed by a progressive decrease, with a mean concentration of 126.2 μg/L at 24 h. The saliva-to-plasma ratio was 32.3–1.2, with a peak of 18.1 at 1.5 h after drug administration. Salivary pH seemed to be affected by MDMA administration; pH values decreased by 0.6 units (mean pH values of 6.9 and 6.8 at 1.5 and 4 h after drug administration vs predose pH of 7.4).

Conclusions: Measurement of MDMA in saliva is a valuable alternative to determination of plasma drug concentrations in both clinical and toxicologic studies. On-site testing is also facilitated by noninvasive and rapid collection of salivary specimens.

Influence of lipophilicity on the diffusion of cephalosporins into the cerebrospinal fluid

The aim of this quantitative structure-activity relationship (QSAR) study was to investigate the influence of lipophilicity on the diffusion of cephalosporins into the cerebrospinal fluid (CSF). The lipophilicity was expressed as the chromatographic capacity factor (log k'w) determined by high-performance liquid chromatography in a reversed-phase system. The penetration of eight cephalosporins into CSF was studied in male Wistar rats receiving the drugs intramuscularly (1.5 mg/kg). One hour after administration, CSF and blood samples were collected, and concentrations of free drug were measured in CSF (CCSF) and in plasma (CP). A significant parabolic relationship was sought between lipophilicity (log k'w) and the capacity of diffusion across the blood-brain barrier expressed as log (CCSF/CP). The cephalosporins exhibiting a moderate lipophilicity diffused well into CSF. A pharmacokinetic study was performed at 1, 2 and 4 h after administration of three cephalosporins: cefazolin, ceftriaxone and cefsulodin. These compounds were choosen according to their lipophilicities (low, moderate and high values, respectively). The AUC0-4h for both free plasma (AUCP) and cerebrospinal fluid (AUCCSF) concentrations were determined. The AUCCSF/AUCP ratio presented a maximum value for a strongly albumin bound cephalosporin, ceftriaxone. In our experimental conditions, the ideal lipophilicity (log k'w) range for diffusion of cephalosporins from plasma into CSF was between 1.6 and 1.8.

Drug monitoring in nonconventional biological fluids and matrices

Determination of the concentration of drugs and metabolites in biological fluids or matrices other than blood or urine (most commonly used in laboratory testing) may be of interest in certain areas of drug concentration monitoring. Saliva is the only fluid which can be used successfully as a substitute for blood in therapeutic drug monitoring, while an individual's past history of medication, compliance and drug abuse, can be obtained from drug analysis of the hair or nails. Drug concentrations in the bile and faeces can account for excretion of drugs and metabolites other than by the renal route. Furthermore, it is important that certain matrices (tears, nails, cerebrospinal fluid, bronchial secretions, peritoneal fluid and interstitial fluid) are analysed, as these may reveal the presence of a drug at the site of action; others (fetal blood, amniotic fluid and breast milk) are useful for determining fetal and perinatal exposure to drugs. Finally, drug monitoring in fluids such as cervical mucus and seminal fluid can be associated with morpho-physiological modifications and genotoxic effects. Drug concentration measurement in nonconventional matrices and fluids, although sometimes expensive and difficult to carry out, should therefore be considered for inclusion in studies of the pharmacokinetics and pharmacodynamics of new drugs.

Stereoselective disposition of ibuprofen enantiomers in human cerebrospinal fluid

Since both (R)- and (S)-enantiomers of ibuprofen may act on the central nervous system, we investigated their plasma and cerebrospinal fluid (CSF) concentrations in 46 patients with nerve-root compression pain requiring a lumbar puncture. Each patient received an oral dose of 800 mg rac-ibuprofen. A single blood and CSF sample was drawn concomitantly from each patient at intervals between 30 min and 8 h after dosing. Both isomers peaked later in the CSF (3 h) than in the plasma (1.5 h). Their CSF concentrations became higher than their concurrent free plasma concentrations after 90 min. The estimated elimination half-lives of (R)- and (S)-ibuprofen were 1.7 h and 2.5 h in plasma and 3.9 h and 7.9 h in CSF, respectively. The AUCCSF/AUCplasma ratios (0, 8 h) were 0.009 and 0.015 for the (R)- and (S)-forms, respectively.

Intracellular accumulation of ofloxacin-loaded liposomes in human synovial fibroblasts

In order to incorporate ofloxacin within liposomes, the reverse-phase evaporation technique was carried out. The liposome lipid matrix consisted of dipalmitoylphosphatidylcholine-cholesterol-dihexadecylphosphate (4: 3:4 molar ratio). The liposome formulation presented a mean size of 185 +/- 31 nm and had an encapsulation capacity of 5.3 microliters/mumol. The liposome formulation was able to deliver ofloxacin into McCoy cells in a greater amount (2.6-fold) than the free drug, improving antibiotic accumulation.

Cerebrospinal fluid retrieval in the conscious dog: a methods development study

A chronic cerebrospinal fluid access system is described for use in the conscious sling-restrained dog. In a pilot study of ten dogs, a fenestrated barium-impregnated silastic catheter was surgically implanted in the subarachnoid space of the second cervical vertebra through a dorsal laminectomy. This fenestrated catheter was coupled to a subcutaneous access port. Following surgery, cerebrospinal fluid was sampled weekly and evaluated for protein content and cytology. The cerebrospinal fluid albumin to serum albumin ratio was calculated for each sample to evaluate blood-brain barrier integrity. The instrumentation was successfully implanted in five of the first eight dogs using a midbody dorsal laminectomy. Cerebrospinal fluid access was maintained in these dogs for 21 +/- 10 days. Using a slight modification of the original technique, the final two dogs were instrumented through a caudodorsal laminectomy of the second cervical vertebra. The cerebrospinal fluid access system remains patent after 444 days of study in these two dogs. Necropsy evaluation suggested that catheter failure in the immediate postoperative period was due to gross malposition of the catheter. Chronic catheter failure occurred secondary to obstruction by local fibrous tissue reaction. Using this instrumentation, a pharmacokinetic evaluation of the plasma and cerebrospinal fluid deposition of an intravenous bolus of acyclovir was successfully performed twice in a single dog without complications. This instrumentation could provide chronic cerebrospinal fluid access for multiple pharmacokinetic studies in the conscious dog.

The passage of cloxacillin into cerebrospinal fluid in the absence of meningitis

1. Eleven patients undergoing lumbar discectomy received cloxacillin by continuous i.v. infusion, starting before the operation. During the operation several blood samples and one CSF sample were taken. 2. Mean rate constants describing the passive transfer of drug from plasma to CSF (kp) and the largely active transfer in the opposite direction (kCSF) were estimated. 3. In some subjects the CSF albumin quotient, defined as the ratio between the albumin concentration in CSF and in plasma times 1000, was slightly elevated (up to 23) which caused a significant increase in the value of kp. 4. The estimate of mean kp for healthy individuals was 0.065 h-1, which corresponds to a half-life of 10 h. The estimate of mean kCSF was 2.10 h-1. This predicts a steady-state CSF drug concentration which is 3% of the unbound plasma drug concentration. 5. There was a significant lag between the time courses of plasma and CSF drug concentrations, presumably reflecting the time for drug to move from the choroid plexus to the lumbar sampling site. 6. Four other patients received cloxacillin for prophylactic or therapeutic reasons by continuous i.v. infusion. In three of those patients the albumin quotient was normal or slightly elevated and the steady-state CCSF/Cu ratio was similar to the predicted normal value. 7. These findings indicate that eradicating staphylococci from CSF in cases of meningitis with a low degree of inflammation may be difficult.

Do anticancer agents reach the tumor target in the human brain?

The development of effective chemotherapy for tumors of the central nervous system (CNS) is complicated in that the blood-brain barrier (BBB) hampers the penetration of most drugs into the brain and cerebrospinal fluid (CSF). This review summarizes the main reports on the distribution to CNS tumors and peritumoral normal brain of antitumor agents such as epipodophyllotoxins, cis-diamminedichloroplatinum(II), some nitrosoureas, bleomycin, vinblastine, and other clinically used antitumor agents as well as that of some experimental compounds with specific physicochemical properties. Drug levels were measured at surgical resection or in autopsy samples taken from patients who presented with different primary brain tumors or with brain metastases from extracerebral tumors. The observations made in each study were summarized in some detail, and the main points were then evaluated comparatively so as to highlight common aspects in the pharmacokinetic patterns of antitumor agents in human CNS tumors. Independently of their physicochemical properties, most antitumor agents appear to accumulate to a greater extent and to persist longer in intracerebral tumors than in the normal peritumoral brain. From in vitro cytotoxicity assays, it appears that epipodophyllotoxins, platinum compounds, bleomycin, and nitrosoureas reach potentially active therapeutic concentrations at the tumor target. However, all drugs have difficulty in reaching brain tissue adjacent to the tumor, as the intact BBB hampers their penetration. Plasma and CSF drug concentrations usually give little useful indication of the absolute quantity of drugs in brain tumors. To obtain a clear understanding of the CNS distribution of antitumor agents, one must determine whether the compound being measured is actually responsible for the observed activity and must consider the role of metabolites in the effect of the parent drug.

Antibiotic tissue penetration and its relevance: models of tissue penetration and their meaning

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Risk-benefit assessment of anaesthetic agents in the puerperium

A critical evaluation of anaesthetic agents in the puerperium is difficult because systematic, relevant studies are still lacking. Current knowledge of the effects of different agents used in labour and caesarean section indicates that significant residual effects on the mother and newborn are limited. In the early puerperium, based on physiological and/or hormonal changes, the mother could be more sensitive to inhalational anaesthetic agents and local analgesics. To date there is no evidence that any anaesthetic agent is excreted in breast milk in clinically significant amounts when given as a single dose. The only exception is perhaps in the case of very premature neonates whose mothers have had multidrug therapy before labour. Even then the importance of breast milk should be carefully assessed against possible adverse drug effect. However, repeated administration of long-acting benzodiazepines and continuous epidural administration of pethidine (meperidine) can have adverse effects on the neonate. The essential conclusion of this review is that breast-feeding is best. The different anaesthetic agents are excreted in the milk in amounts so low that detrimental effects on the neonate should not be expected.

Pharmacokinetics and tissue concentrations of cefuroxime

Cefuroxime is well-absorbed and distributed over the human body. This review gives a general summary of published information on tissue concentrations of cefuroxime after an intravenous or intramuscular dose of 750 or 1,500 mg of cefuroxime. Tissue concentrations are given for blister fluid, meninges, eyes, respiratory tract, sputum and bronchi, abdominal and urogenital tract, uterine, ovarian and fallopian tube tissue, myometrium, membranes, placenta, puruloid and healthy human milk, bile, prostate, hip and knee bone. Pharmacokinetics are reviewed in patients with impaired kidney function and in pregnancy.

Plasma and cerebrospinal fluid concentrations of indomethacin in humans. Relationship to analgesic activity

Plasma and cerebrospinal fluid (CSF) concentrations of indomethacin have been determined in 52 patients hospitalized for nerve-root compression pain. Samples of blood and CSF were collected at the same time in each subject, 0.5 to 12 h after a single intramuscular injection of 50 mg indomethacin. Analgesic effect was assessed by the absolute and percentage variation in Huskisson's visual analogue scale between dosing and sampling. According to its high lipid solubility, indomethacin rapidly crossed the blood-brain barrier, being detected in CSF 0.5 h after administration. After attainment of equilibrium within 2 h, the CSF level exceeded the free plasma level. Since the drug was extensively bound to serum albumin (99.7 +/- 0.1%), this phenomenon may represent a slight degree of binding of indomethacin in CSF. The analgesic activity was not related to either the plasma or CSF concentration of indomethacin.

Modeling the enhanced uptake of zidovudine (AZT) into cerebrospinal fluid. 1. Effect of probenecid

The kinetics of zidovudine (AZT) distribution into rabbit cerebrospinal fluid (CSF) were studied during continuous infusion of AZT and after iv bolus administration. The CSF/plasma steady-state AZT concentration ratio was 0.192 +/- 0.003. That this ratio is less than unity, and the clearance from the CSF due to bulk flow is much smaller than the total CSF-to-plasma clearance, suggests active CSF-to-plasma transport of AZT. Probenecid coadministration significantly enhances AZT distribution into CSF when plasma and CSF concentrations of AZT are at steady state during continuous infusion of AZT or at a transient steady state after a single iv bolus dose administration. A linear pharmacokinetic model which describes the distribution of AZT into CSF and relates intercompartmental clearances between CSF and plasma was developed and was used to analyze the results. This analysis showed that probenecid enhances the distribution of AZT into the CSF by its effect on clearances between plasma and CSF. The CSF exit-rate constant for AZT estimated during probenecid coadministration was significantly different from controls. Probenecid coadministration resulted in a 36% reduction in the CSF-to-plasma transfer-rate constant. Reduction in the CSF to plasma clearance of AZT is probably due to the effect of probenecid on the active CSF-to-plasma transport of AZT. The model analysis also indicates that probenecid may have increased the plasma to CSF clearance of AZT. There was an increasing trend in the steady-state CSF/plasma AZT concentration ratio with increasing plasma probenecid concentrations. These results are consistent with probenecid competitively inhibiting the CSF-to-plasma transport of AZT.

Comparison of propofol and thiopentone for induction of anaesthesia for elective caesarean section

Propofol 2.5 mg/kg was compared with thiopentone 5 mg/kg as an induction agent for elective Caesarean section. Thirty-two healthy women with cephalopelvic disproportion were included in an open randomised study. The placental transfer of propofol was also studied in 10 other mothers given a single dose of 2.5 mg/kg. The induction characteristics and haemodynamic response to propofol and thiopentone were similar. Side effects were rare with both agents, but propofol caused more discomfort on injection compared to thiopentone. Recovery times were shorter after propofol as evaluated by time to orientation, recovery scoring after anaesthesia and measurements with the Maddox wing. Rapid placental transfer and significant fetal uptake were detected for propofol. There was no significant neonatal depression as assessed by Apgar scores and blood gas analyses. Propofol appears to be a suitable alternative to thiopentone as an induction agent for anaesthesia in elective Caesarean section.

Pharmacokinetics of scopolamine during caesarean section: relationship between serum concentration and effect

The pharmacokinetics (radioreceptor assay, RRA) and some of the clinical effects of the anticholinergic agent, scopolamine, were studied in 16 parturients during caesarean section. Following a single 0.005 mg/kg intramuscular injection (deltoid muscle), a very fast rate of absorption was found with mean peak serum concentrations occurring after only 10 min (n = 6). Due to severe bradycardia, 0.5 mg of atropine i.v. had to be given in addition to the i.m. scopolamine treatment to one parturient. The RRA measured the total concentration produced by the two anticholinergic agents in both serum and urine. There was a fundamental difference in the diffusion of scopolamine through the placenta and the blood-lumbar (CSF-barrier (n = 15). There was significant drug penetration in the foeto-placental unit, indicating an efficient drug transfer to the child, but there were measurable levels of the drug in the lumbar CSF in only three cases. The apparent elimination phase half-life of scopolamine in serum was only around 1 h. The urinary excretion of scopolamine and/or its antimuscarinic metabolites lasted only for 6 h (2.63 +/- 1.14% of the dose). The onset of the clinical effects of scopolamine appeared to be delayed, but long-lasting in contrast to the rapid absorption and quick disappearance from the serum. Both the heart rate changes, sedative and antisialogogue effects and serum concentrations did not show any correlation. There appears to be a surprisingly great difference between the pharmacokinetic parameters and the clinical effects of scopolamine.

Intramuscular atropine in elderly people: pharmacokinetic studies using the radioreceptor assay and some pharmacodynamic responses

The pharmacokinetics (radioreceptor assay, RRA) and some clinical effects of atropine were studied in 7 elderly gynaecological surgery patients. The RRA measures only the pharmacologically active isomer of atropine, 1-hyoscyamine. Following a single 0.01 mg/kg intramuscular (M. deltoideus) injection, a very fast rate of absorption was found with mean peak serum concentration occurring after only 13 min. The reason for this could be either a preferential tissue uptake of the 1-form or the injection site or both. The elimination half-life was 2.27 hr. Only 23.1% of the given drug was excreted in urine in 24 hr as a pharmacologically active form. The clinical effects (heart rate rise, subjective sedation and antisialogogue effect) were seen after only 30 min. This somewhat faster appearance of clinical effects than in previous studies can be due to the injection site. The sedative effect of the drug is clear and long lasting in elderly people.

Clinical pharmacokinetics of nonsteroidal anti-inflammatory drugs in the cerebrospinal fluid

The pharmacokinetics of nonsteroidal anti-inflammatory drugs (NSAIDs) in the cerebrospinal fluid (CSF) is of clinical interest as it may be related to some of their properties and side-effects. Two types of NSAIDs can be described with respect to their concentration and time course in CSF: in the first type, the transfer across the blood-brain barrier seems to be controlled by simple physico-chemical factors. These drugs (oxyphenbutazone, indomethacin, ketoprofen) are characterized by a high lipophilicity. At steady state, their free plasma concentrations correspond to their CSF concentrations. The second group consists of more hydrophilic compounds (salicylates); there is no correlation between plasma concentrations and CSF concentration. Further investigation needs to be carried out on CNS side-effects and the antialgesic activity of salicylates in relation on their CSF distribution.

Application of serial sampling of cerebrospinal fluid in pharmacodynamic studies with a drug active in the CNS: heptabarbital concentrations at onset and offset of loss of righting reflex in rats

As cerebrospinal fluid (CSF) possesses unique characteristics in order to explore concentration-pharmacological response relationships of drugs active in the CNS, the practicability of serial sampling of CSF was tested in a study with heptabarbital. Concentrations in CSF and plasma were measured simultaneously in individual rats during and after an intravenous infusion for 30 min. At the end of the infusion, the distribution equilibrium was attained with a CSF/plasma concentration ratio of 0.38, roughly equal to the fraction unbound to protein. When concentrations in blood and CSF were determined at the onset and offset of loss of righting reflex concentrations in blood were significantly greater at onset (146 +/- 19 mg/l) than at offset (108 +/- 16 mg/l, n = 6), whereas concentrations in CSF were identical (39 +/- 5 and 38 +/- 5 mg/l, respectively). This confirmed the earlier observation that the CSF is pharmacokinetically indistinguishable from the site of action. When the duration of the loss of righting reflex was varied, concentrations of heptabarbital in CSF at onset and offset were similar, independent of the duration of the loss of righting reflex (1-5 hr). These findings demonstrate the absence of the development of acute tolerance and confirmed that no (inter)active metabolites interfered with the pharmacological response. In a total number of 26 rats the concentrations in CSF at onset and offset of loss of the righting reflex were compared. The interindividual variation was 13-15% and the intra-individual variation was only 4-6%. The results demonstrate the usefulness of serial sampling of CSF in pharmacodynamic studies with centrally acting drugs.

Placental and blood-CSF transfer of orally administered diazepam in the same person

Both placental and blood-lumbar CSF transfer of diazepam (5 mg orally) and its two metabolites, N-desmethyldiazepam and unconjugated oxazepam, was measured (by GLC) in 15 patients undergoing Caesarean section under spinal analgesia. Differing from our earlier studies with atropine (Virtanen et al. 1982; Kanto et al. 1981 & 1987), a reasonably fast penetration of diazepam and its two metabolites through the two biological membranes was found. Diazepam, N-desmethyldiazepam and to a lesser extent unconjugated oxazepam accumulated on the foetal side of the placenta, apparently due to a higher degree of plasma protein binding in the foetus. No accumulation was found in CSF, probably due to the lack of binding proteins in this tissue compartment. Concerning atropine, lumbar CSF with an incomplete drug penetration was found to be a "deeper" compartment than amniotic fluid, but in the present study with diazepam there was no clear difference between these two tissue compartments.

Effect of dose and repeat intravenous 24 hr infusions of methotrexate on cerebrospinal fluid availability in children with hematological malignancies

This pharmacokinetic study examined the relationship between methotrexate (MTX) dose and drug concentrations in blood and cerebrospinal fluid (CSF) during repeated 24 hr infusions. Two regimens were used: an intermediate dose (ID) of 0.5 g/m2 (7 patients, 23 cycles) and a high dose (HD) of 2.5 g/m2 (8 patients, 39 cycles). Inter-patient variability in the drug concentration was apparent in serum and CSF for both doses. The dispersion was particularly wide in CSF for HD MTX. Considering median values, serum and CSF MTX were linked to dose escalation. Individual CSF/serum drug ratios were not modified by the dose (1.1% for ID MTX versus 1.4% for HD MTX). A potentially cytotoxic drug level in CSF (10(-6) M) was never obtained for ID MTX cycles, but was achieved in 44% of HD MTX cycles: for HD MTX, this corresponded to 88% of patients (7/8). Total body clearance did not modify the degree of CSF MTX passage. A positive, significant correlation (r = 0.62, P less than 0.05) was observed for ID MTX between individual serum and CSF MTX; no such relationship was seen with HD MTX. Individual cycle-to-cycle variations in the MTX concentration were particularly marked in CSF and for HD MTX, without strict concordance with blood levels.

Placental and blood-CSF transfer of intramuscularly administered atropine in the same person

Both placental and blood-CSF transfer of atropine (0.01 mg/kg intramuscularly) was measured (by RIA) in 11 parturients undergoing Caesarean section under spinal analgesia. In the foeto-placental unit a significant penetration into amniotic fluid was found, whereas in CSF there was a measurable level of the drug (greater than 1.5 ng/ml) in only one mother. Our results show that there is a fundamental difference in the penetrability of tertiary ammonium alkaloids like atropine through these two biological membranes. However, our results concern penetration into human lumbar CSF and do not necessarily reflect potential penetration into the ventricular CSF, choroid plexus or brain ventricular ependyma.

Oral temazepam as a premedicant in elderly general surgical patients

In elderly, general surgical patients, oral temazepam 20 mg given in a soft gelatin capsule proved to be a useful light premedicant when given before spinal anaesthesia. In comparison with placebo, it caused preoperative subjective sedation, prevented an increase in heart rate and decreased serum cortisol, but not serum antidiuretic hormone levels. However, simple devices (linear analogue scale, Maddox wing test, critical flicker fusion apparatus) appeared to be quite ineffective in differentiating the clinical effects of temazepam from those of placebo. Temazepam given in a soft gelatin capsule to patients in the supine position had a reasonably fast gastrointestinal absorption, but its blood-lumbar cerebrospinal fluid penetration rate appeared to be quite slow.

Obstetric analgesia. Clinical pharmacokinetic considerations

All drugs used in obstetric analgesia are more or less lipophilic, their site of action is in the central nervous system, and they have good membrane penetrability in the fetomaternal unit. Thus the dose and method of administration as well as the duration of treatment are important clinical determinants of drug effects in the fetus and newborn. In the past, too much emphasis has been placed on fetomaternal blood concentration ratios of different agents; it is now appreciated that the extent of fetal tissue distribution and the neonatal elimination rate are pharmacokinetically much more important. Extensive fetal tissue distribution is reflected in a low fetomaternal drug concentration ratio, which may be followed by prolonged neonatal elimination of the drug. Currently, the most effective and safest method for obstetric analgesia is regional epidural administration of bupivacaine or lignocaine (lidocaine); only low doses are needed and the newborn is able to handle these agents efficiently. On the basis of pharmacokinetic and neurobehavioural assessments, inhalational anaesthetic agents appear to be more attractive than pethidine (meperidine) or benzodiazepines. Intermittent administration and fast pulmonary elimination of inhalational agents ensure that long-lasting residual effects are unlikely to occur. The kinetics of epidural and intrathecal opiates explain the problems associated with their use in obstetrics. Among the newer drugs used in obstetric analgesia, the properties of meptazinol and isoflurane appear interesting and these agents warrant further study. All drugs used in obstetric analgesia have a potentially detrimental effect on the neonate and, therefore, knowledge of fetal and neonatal pharmacokinetics is of importance to the clinician.

A comparison of the soft gelatin capsule and the tablet form of temazepam

Pharmacokinetics and pharmacodynamics of the soft gelatin capsule and tablet form of temazepam were compared. In a single blind study, six healthy volunteers, in the supine position, took either a tablet of temazepam 20 mg or a soft gelatin capsule of temazepam 20 mg. Sixty gynaecological in-patients received either a tablet or a soft gelatin capsule of temazepam 20 mg the night before surgery as premedication. Subjective parameters were assessed in the morning. The soft gelatin capsule yielded clearly higher serum concentrations during the first hour after administration. In the pharmacodynamic parameters there were slight but insignificant differences in favour of the capsule form. As a premedicant the capsule resulted in a significantly (P less than 0.01) shorter delay in the onset of sedative action and to an almost significant (P less than 0.05) delay in falling asleep; also an almost significantly (P less than 0.05) longer action of sleep in comparison with the tablet.

Midazolam: the first water-soluble benzodiazepine. Pharmacology, pharmacokinetics and efficacy in insomnia and anesthesia

Midazolam is a 1,4-benzodiazepine derivative with a unique chemical structure: depending on environmental pH, the drug can produce highly water-soluble salts (pH less than 4) or exist in lipophilic diazepine ring-closed form (pH greater than 4). This characteristic contributes to rapid onset of action and to good local tolerance after parenteral administration. After both oral and parenteral administration, midazolam has a fast absorption rate and is rapidly excreted, with a half-life of only about 2 hours. A reasonably good correlation has been found between plasma levels and clinical effects, indicating a fast but brief response. As a hypnotic, midazolam is mainly indicated in insomniac patients with difficulties in falling asleep or having a pathologic sleep pattern during the first half of the night. No marked hangover effects are present the next morning. In anesthesiology, midazolam appears to be a useful, short-acting, sedative-anxiolytic and amnesic premedicant after both oral and parenteral administration. In minor surgery, however, the slow, unpredictable onset and variable duration of action, as compared with thiopental, may inhibit its routine use as an induction agent, especially in young patients, without heavy premedication. In major surgery, midazolam is an alternative to thiopental for induction of anesthesia in spite of its slow, variable induction time. Its advantages include good cardiovascular stability, transient and mild respiratory depression, low frequency of venous irritation, production of anterograde amnesia and short duration of action in comparison with other benzodiazepines.

Protein binding and CSF penetration of phenytoin following acute oral dosing in man

Prophylactic phenytoin (DPH) has been evaluated in 20 patients undergoing diagnostic myelography. DPH (0.75 g) was ingested at 20.00 h the night before and 0.5 g at 08.00 h on the morning of the procedure. Total DPH concentrations at myelography (mean +/- s.d.: 12.7 +/- 4.3 mg l-1; range 6.3-21.5 mg l-1) correlated with CSF values (1.3 +/- 0.46 mg l-1; range 0.7-2.2 mg l-1; r = 0.83, P less than 0.001). DPH protein binding at that time varied two-fold (9.2-18.5%) and free drug levels (1.7 +/- 0.6 mg l-1) correlated with CSF (r = 0.83, P less than 0.001) and total (r = 0.89, P less than 0.001) plasma DPH concentrations. There were significant negative correlations between patient weight (n = 17) and total (r = 0.57, P less than 0.05) and CSF (r = -0.55, P less than 0.05) DPH concentrations at myelography. Total plasma DPH levels 8 h (14.5 +/- 3.9 mg l-1; range 7.3-20.6 mg l-1) and 24 h (12.3 +/- 3.8 mg l-1; range 5.0-19.8 mg l-1) after myelography were largely within the 'therapeutic range' of 10-20 mg l-1 for the drug. No patient suffered a seizure although, in two, spike discharges were seen on a post-myelography electroencephalogram. A simple regime involving two doses of DPH would provide acceptable plasma CSF concentrations as a basis for controlled studies in seizure prophylaxis following neuroradiological investigations involving intrathecal contrast.

Diffusion of intramuscular ketoprofen into the cerebrospinal fluid

Serum and cerebrospinal fluid (CSF) concentrations of ketoprofen have been measured in 36 patients hospitalised for sciatica. Diagnostic lumbar puncture was done 15 min to 13 h after a single 100 mg intramuscular dose of ketoprofen. Serum and CSF were sampled at the same time. Free serum concentrations were determined by equilibrium dialysis. Total and free concentrations were assayed by a highly sensitive and specific HPLC method. Ketoprofen rapidly crossed the blood-brain barrier and was detected in CSF 15 min after its administration. The rapid diffusion can be explained by the high lipid solubility of the drug. The CSF level was in equilibrium with the free serum concentration from the second to the 13th hours.

Pharmacokinetics of vinpocetine and its metabolite, apovincaminic acid, in plasma and cerebrospinal fluid after intravenous infusion

The pharmacokinetics of vinpocetine (ethyl apovincaminate, Cavinton) and its metabolite, apovincaminic acid, was studied in patients with cerebrovascular disorders. Vinpocetine (1 mg/kg) was infused intravenously over 25 min. The elimination half-life of the parent drug in plasma was 4.7+/-2.13 h. Total clearance of vinpocetine was 0.79+/-0.1 1 h(-1) kg(-1). The presence of vinpocetine in cerebrospinal fluid shows that the drug is able to pass through the blood-brain barrier and reach the central nervous system which is a possible site of action. The maximum increase of cerebral blood flow (25%) was measured at 32 min after the start of the infusion.

Toxic effects of chemicals: difficulties in extrapolating data from animals to man

This review attempts an analysis of the major components which make it extremely difficult to extrapolate toxicological data obtained with chemicals from animals to man. A first problem concerns the use of doses to express the unit of comparison across animal species; the dose is a parameter exogenous to the body and when a chemical enters the body concentrations should be utilized. There is in fact evidence that for several chemicals equal doses in different animal species do not mean equal concentrations in blood or tissues. Concentrations of chemicals should be measured for extrapolation purposes as close as possible to the site of the toxic effect. A second problem regards the fact that several chemical are transformed in the body into other chemical species--sometimes few and sometimes many--and some of these species (active metabolites) display biological activity in some cases higher than different from or antagonistic to those of the parent compounds. Some of these metabolites are highly reactive and therefore bind to body components, particularly macromolecules such as proteins and nucleic acids. There is evidence that metabolism is quantitatively and/or qualitatively different in various animal species. A third problem concerns the difference in various animal species in the biological substrates on which chemicals exert their toxic effects. Equal concentrations of chemicals and their metabolites do not mean equal toxic effects across animal species because endogenous metabolic processes, cell permeability, enzymes, and receptors are not necessarily the same in animals and man. To overcome these difficulties there is a need for closer integration of different disciplines in the toxicological evaluation of chemicals. A scientific rather than a routine approach in toxicology is emphasized.

Pharmacokinetic aspects of spinal morphine analgesia

Epidural (E.D.) and intrathecal (I.T.) morphine (M) analgesia were studied in patients with pain after thoracotomy. The role of the pharmacokinetic properties of M. for the associated analgesia was also evaluated. M. concentrations in CSF and plasma were assayed using gas chromatography with EC detection. Analgesia was evaluated as the time postoperative until the patients again required analgetics and were given meperidine intramuscularly (I.M.) for thoracic pain. A lumbar site of E.D. and I.T. injection of M. resulted in a variable but in general longlasting postoperative analgesia although delayed after I.T. administration. The mean duration of analgesia after E.D. administration was dose-related (8.6 +/- 2.0 h, 13.0 +/- 3.5 h, and 15.6 +/- 2.6 h; means +/- SEM for the 2, 4 and 6 mg groups, respectively), which was comparable to that achieved after I.T. administration of 0.25 to 0.50 mg M. M. concentrations in plasma after E.D. administration were comparable in variability and magnitude to those found after I.M. administration. The concentrations of M. in plasma were not related to the long duration of analgesia and may only contribute to analgesia shortly after the E.D. administration. The reported time course of analgesia after E.D. injection with a delayed onset corresponded with the appearance of M. in the CSF. Fifteen min after E.D. administration, M. was found in higher concentrations in CSF than in plasma, but peak levels were not seen until 2 h after the injection. Both the high content of M. in CSF as expressed by AUC, as well as peak concentrations in CSF, were related to the longlasting analgesia after E.D. administration. A protracted clearance of M. from the CSF as a cause of longlasting analgesia was not found, M. was eliminated with a similar half-life from CSF and plasma. The high CSF concentrations of M. seen after E.D. administration were the result of a direct uptake across the dura. In contrast, the appearance of M. in CSF after I.M. administration of 10 mg was slower. Maximal concentration of M. in the CSF was reached after 3 h and the peak levels were on average about 100 times less than those found after E.D. injection of 6 mg morphine. CSF and plasma reached pseudoeliquilibrium at a ratio around 0.9 after I.M. administration. This is to be compared with a CSF/plasma concentration ratio around 100 after E.D. administration. A comparison of M. concentrations in the CSF after thoracic and lumbar E.D. injection showed that spinal CSF rapidly yielded comparable concentrations at the lumbar level.(ABSTRACT TRUNCATED AT 400 WORDS)

Plasma protein-binding and CSF concentrations of valproic acid in man following acute oral dosing

Simultaneous cerebrospinal fluid (CSF), total and free plasma valproic acid (VPA) concentrations were measured in 17 patients receiving two weight-adjusted VPA doses as seizure prophylaxis prior to diagnostic myelography or cisternography. Free drug concentrations were similar when measured by equilibrium dialysis (ED) at 37 degrees C for 24 h (Dianorm) or by a novel ultrafiltration (UF) method (EMIT freelevel system 1, SYVA) (ED:2.3-35.5 mg-1; UF:1.3-33.6 mg-1; r = 0.78, P less than 0.002). There was wide variation in total VPA concentration (39-154 mg-1) and in free fraction (ED: 3.3-25.6%; UF: 5.9-24%). Concentration dependent protein binding was not demonstrated. CSF VPA varied between 4.2 and 25.6 mg-1 and was accurately reflected by free plasma VPA concentrations (ED: r = 0.75, P less than 0.005: UF: r = 0.93, P less than 0.001). CSF concentration also correlated with the total plasma VPA (r = 0.76, P less than 0.005). The Emit freelevel system 1 provides a rapid measure of unbound VPA in the plasma which may be suitable for routine clinical use.

Penetration of lidocaine and its active desethylated metabolite into cerebrospinal fluid in man

Penetration into lumbar cerebrospinal fluid (CSF) of lidocaine and its active desethylated metabolite, monoethylglycinxylidide (MEGX), has been studied in 10 neurological patients after a single subcutaneous injection of 2 mg/kg prior to lumbar puncture. An HPLC method was used to assay lidocaine, MEGX and glycinxylidide (GX) in serum and CSF. The serum protein unbound fraction of lidocaine was determined by equilibrium dialysis. The mean peak serum lidocaine concentration was found 25 minutes after injection, and the corresponding peak CSF level occurred after 70 min. A similar slow penetration of MEGX into CSF was observed, which indicates low membrane permeability for these two agents. No GX was found. The steadily increasing CSF lidocaine/serum total lidocaine ratio throughout the period of study up to 120 min and the higher level in CSF than the corresponding unbound fraction of the total serum lidocaine indicate that serum protein binding is not the sole determinant of the penetration of lidocaine into lumbar CSF. Rapid accumulation in brain tissue and diffusion back into cerebral extracellular fluid and to lumbar CSF may also occur. The apparent slow membrane penetration of lidocaine and its desethylated metabolite may be one reason for the difficulty of controlling lidocaine infusion rates according to therapeutic effectiveness and side-effects.