Plasma protein binding of drugs in pregnancy

The degree of binding to plasma proteins is an important determinant of drug disposition and response. Normal human pregnancy is associated with concentration of plasma proteins, free fatty acids and possibly other endogenous substances interfering with drug binding. The possibility of an associated change in plasma binding capacity therefore needs to be taken into consideration. Experimental studies conducted mostly in vitro have shown that the plasma protein binding of many (but not all) drugs is decreased during pregnancy, particularly during the last trimester. This phenomenon should be taken into account when interpreting serum concentrations of total (free + protein-bound) drug in clinical practice. Notable examples of drugs whose unbound fraction increases during pregnancy include diazepam, valproic acid, phenytoin, phenobarbitone, salicylic acid, pethidine, lignocaine, dexamethasone, sulphafurazole and propranolol. For many drugs, important differences have been demonstrated in the degree of protein binding between maternal and cord plasma. In some cases, this may provide an explanation for the finding of marked differences in total drug concentration between maternal and fetal plasma at the time of delivery.

Disposition of sodium valproate in epileptic patients

1 Serum levels of valproic acid have been determined at fixed intervals after the administration of single oral and intravenous doses (800 mg) to six epileptic patients receiving chronic treatment with other antiepileptic drugs. 2 Serum levels declined monoexponentially shortly after the intravenous administration. Biological half-lives averaged 9.0 +/- 1.4 h (s.d.). Volumes of distribution were 0.175 +/- 0.025 l/kg. There was a statistically significant negative correlation between volumes of distribution and serum half-lives (P less than 0.005). 3 After oral doses serum levels rose rapidly to peak values within 0.5--2 h. Biological availability was 96 +/- 9%. 4 Comparison with a previous study performed according to the same protocol in healthy volunteers showed significantly increased volumes of distribution and rates of elimination in the patients. Total serum clearance was 85% higher in the patients as compared to the healthy subjects (P less than 0.001). Possible explanations for these findings are discussed.

Interaction between phenytoin and valproic acid: plasma protein binding and metabolic effects

The effect of sodium valproate (400 mg three times daily) on the disposition kinetics of intravenous phenytoin (250 mg) was investigated in seven normal subjects. After valproate, the free (unbound) fraction of phenytoin in serum rose from 9.6 +/- 0.9% (SD) to 15.6 +/- 1.4% on average (p < 0.001). The effect was associated with an increase in systemic clearance and apparent volume of distribution of total drug. There was a strong positive correlation between percent increment in each of these parameters and percent increment in unbound drug in serum. Free phenytoin concentration in serum and phenytoin concentration in saliva increased during valproate administration. As a result, both the clearance and the apparent volume of distribution of free drug were reduced. There was an increase in the renal excretion of unchanged phenytoin during valproate administration, but the effect was too small to have an appreciable influence on the overall clearance of the drug. There were no consistent changes in the excretion of the major metabolite 5, p-hydroxyphenyl, 5-phenyl, hydantoin (pHPPH), in the urine. These results suggest that valproic acid may have two separate and opposing effects on phenytoin disposition: (1) displacing phenytoin from plasma protein binding sites, thereby enhancing the systemic clearance of total drug, and (2) inhibiting phenytoin metabolism, thereby increasing the concentration of free drug in the serum.

The effect of catecholamines and sympathetic stimulation on the release of acetylcholine from the guinea-pig colon

1. In isolated guinea-pig terminal colon, the effect of sympathetic stimulation on contraction and acetylcholine release elicited by pelvic and transmural stimulation was investigated.2. Sympathetic stimulation reduced the nerve-mediated contractile responses more than those produced by added acetylcholine.3. Sympathetic stimulation also reduced the acetylcholine released during pelvic and transmural stimulation at low frequency. The inhibitory effect on acetylcholine released from resting colons is concealed by the simultaneous release of acetylcholine in considerable amounts from stimulated periarterial nerves which probably contain parasympathetic fibres.4. The inhibitory effect of endogenous and exogenous catecholamines prevails when cholinergic neurones fire at low rates. It was confirmed that adrenaline is more active than noradrenaline.5. The release of acetylcholine from unstimulated colons was for the most part maintained by nerve-conducted activity, because tetrodotoxin was able to reduce it to about one-tenth.6. It is suggested that the sympathetic control of gastrointestinal tone and motility is exerted through two different routes: inhibition of intramural cholinergic plexuses and direct relaxation of smooth muscle cells.7. The possible site and mechanism of action of catecholamines on intramural cholinergic structures is briefly discussed.

A pharmacological analysis of the peristaltic reflex in the isolated colon of the guinea-pig or cat

1. The peristaltic reflex in the colon was elicited by a localized intraluminal stimulus. The contractile response of the longitudinal coat, which consists of two phases, begins before the start of propulsion. Although the contractions of the longitudinal and circular musculature are usually associated, they may be independent of each other. In particular, the longitudinal contraction does not seem to be necessary for propulsion.2. Both the longitudinal reflex contraction and the segmental responses of the circular muscle to distension, namely a contraction above and a relaxation below the bolus, are abolished by tetrodotoxin and ganglion blocking agents.3. In the guinea-pig, longitudinal and circular reflex contractions are usually resistant to antimuscarine, antihistamine and antitryptamine drugs but in the cat they are abolished by antimuscarine drugs. In both species, however, atropine and hyoscine can impair propulsion by blocking selectively the descending inhibition. In the cat, it is possible to find doses which abolish the descending inhibition without affecting the contractile responses of the longitudinal and circular muscle.4. Sympathetic denervation and pretreatment with reserpine do not affect the propulsive activity. The maintenance of the descending inhibition in denervated organs suggests that the inhibitory neurones to the circular muscle are not adrenergic.5. On the basis of the effects of drugs, the possible nervous mechanism subserving the polarity of propulsion has been examined. Such a mechanism seems to require an inhibitory pathway involving muscarinic receptors at some point.6. Pelvic nerve stimulation facilitates propulsive activity. The effect of transmural stimulation is different at low and at high frequencies of stimulation. The inhibitory effect of sympathetic stimulation on the reflex responses seems to be due mainly to an action on intrinsic nervous structures.

Some observations on the intrinsic nervous mechanism in Hirschsprung's disease

Both at rest and during transmural stimulation acetylcholine output from isolated longitudinal and circular muscle strips is significantly higher in the spastic segment than in the proximal dilated bowel. No difference has been found in the tissue concentration of acetylcholine between ganglionic and aganglionic specimens. The pattern of response to transmural stimulation is also similar in the spastic and dilated bowel. However, after cholinergic and adrenergic blockade transmural stimulation fails to induce relaxation in aganglionic specimens, as it does in normal colon. The hypotheses are advanced that the increase in acetylcholine output may be partly dependent on a failure of the intrinsic modulating mechanisms and that an alteration of the non-adrenergic inhibitory neurons may be involved in the motor disturbances of the aganglionic tract.

Vagal non-adrenergic inhibition of guinea-pig stomach

1. The effect of vagal and sympathetic stimulation on the mechanical and electrical activity (intracellular recording) of the body of the guinea-pig stomach was investigated in vitro.2. Following atropine, 1 x 10(-6)-1 x 10(-7) g/ml., vagal responses were reversed from excitatory to inhibitory.3. Sympathetic blockade, produced by alpha- and beta-receptor antagonists and adrenergic neurone-blocking agents, reduced or abolished sympathetic, but not vagal inhibition.4. Hexamethonium (5 x 10(-5) g/ml.) reduced vagal relaxation to 11-30% according to the stimulation rate. The residual response was maintained in the presence of 5-hydroxytryptamine tachyphylaxis.5. Many muscle cells were observed to be under the influence of both vagus and sympathetic nerves: the effect of sympathetic stimulation was always inhibitory in nature, but high stimulation rates were required. The effect of vagal stimulation was both excitatory and inhibitory even in the absence of atropine: low stimulation rates gave rise either to E.J.P.s (excitatory junctional potentials), often followed by spikes, or to I.J.P.s (inhibitory junctional potentials).6. In some spontaneously firing cells the interruption of electrical activity produced by vagal stimulation at 2/sec and sympathetic stimulation at 20/sec was recorded for a long enough time to check the effect of guanethedine (5 x 10(-6) g/ml.): the drug selectively blocked sympathetic inhibition.7. The significance of the inhibitory non-adrenergic transmitter, released by the intramural neurones activated by preganglionic vagal fibres, is discussed.

Hyoscine-resistant peristalsis in guinea-pig ileum

The effect of hyoscine on the peristaltic activity of the proximal and distal ileum of the guinea-pig was studied. Hyoscine strongly impaired peristalsis as indicated by the elevation of the threshold pressure and by the increased number of incomplete peristalses and blockades. Functional activity of the circular musculature was more markedly impaired. However, particularly in the distal ileum, complete peristalses occurred even after 70 min exposure to hyoscine at a concentration of 10(-6) g/ml. A tenfold increase in hyoscine concentration failed to produce further impairment of peristaltic activity and of the oral reflex contraction. The activity which remained in the presence of hyoscine was blocked by methysergide and by d-tubocurarine. The hypothesis is advanced that once the muscarinic receptors have been blocked, increased radial stretch of the circular coat results in activation of a separate, tetrodotoxin sensitive, excitatory nervous pathway, which is sufficient to maintain a discrete degree of peristaltic activity.

Reevaluation of prognostic significance of symptoms in Hodgkin's disease

The prognostic value--at diagnosis--of fever, sweating and weight loss, which enter the Ann Arbor B category, and of pruritus, whose influence on survival is still debated, were systematically reevaluated in 635 patients with Hodgkin's disease, observed between 1972 and 1982. By means of multivariate analysis an intrinsic, more negative prognostic value was demonstrated for each of the following symptoms: fever over 38 degrees C, weight loss more than 10% of body weight in the 6 months before admission, and severe pruritus, which is defined as being generalized, causing multiple excoriations and resisting local and systemic antipruritics. Patients with the mild counterparts of these symptoms, as well as sweats, were found to have a survival rate quite comparable with that of fully asymptomatic patients. A rearrangement of the Ann Arbor B constitutional symptoms which would replace sweats with severe pruritus might be more correct and more suitable for better selecting the patients who require more aggressive therapy.

Pharmacokinetics of the total triterpenic fraction of Centella asiatica after single and multiple administrations to healthy volunteers. A new assay for asiatic acid

A new HPLC assay method was used to investigate the pharmacokinetics of asiatic acid after oral administration of the total triterpenic fraction of Centella asiatica in single doses (30 or 60 mg) and after a 7-day treatment (30 or 60 mg twice daily). Twelve healthy volunteers received each treatment following a randomized cross-over design with trials separated by a 3-week interval. The time of peak plasma concentration was not affected by dosage difference or by treatment scheme. Differences in peak plasma concentration and area under the concentration vs. time curve from 0 to 24 h (AUC0-24) calculated after 30 or 60 mg administration (single dose) were accounted for by the different dose regimen. However, after chronic treatment with both 30 and 60 mg, peak plasma concentrations, AUC0-24 and half-life were significantly higher than those observed after the corresponding single dose administration. This phenomenon could be explained by a metabolic interaction between asiatic acid and asiaticoside, which is transformed into asiatic acid in vivo.

Pharmacokinetic and pharmacodynamic studies following the intravenous and oral administration of the antiparkinsonian drug biperiden to normal subjects

The pharmacokinetics and pharmacodynamics (changes in pupil size and salivary flow) of biperiden following a single oral and intravenous dose were investigated in six normal subjects. After the injection plasma concentrations declined biphasically, with half-times of 1.5 h for the rapid phase and 24 h for the terminal phase. Clearance and apparent volume of distribution were high (12 ml X min-1 X kg-1 and 24 l X kg-1 respectively). Absorption was rapid but the systemic availability was incomplete (33%), probably due to first-pass metabolism. Central nervous system (CNS) adverse effects and changes in pupil size were observed after both routes of administration while salivary flow was affected only by the injection.

Purine receptors in the guinea-pig internal anal sphincter

1 In the isolated internal anal sphincter of the guinea-pig, adenosine 5'-triphosphate (ATP) and adenosine induced a concentration-dependent and tetrodotoxin-insensitive relaxation. 2 Pretreatment with theophylline (25-50 microM) had no significant effect on the concentration-response curves obtained with either purine compound. 3 Reactive blue 2 (25-100 microM) shifted the curve to ATP to the right in a dose-dependent fashion leaving that to adenosine unaltered. The antagonism appeared to be non-competitive. 4 Neither reactive blue 2 nor purine receptor occupation by ATP or adenosine altered the electrically-induced non-adrenergic, non-cholinergic inhibitory response. 5 The actions of ATP and adenosine in the guinea-pig internal anal sphincter appear to be mediated by separate receptors. These receptors are not involved in the nerve-mediated relaxation.

An in vitro study of the relationship between GABA receptor function and propulsive motility in the distal colon of the rabbit

1. The effects of gamma-aminobutyric acid (GABA), 3-aminopropane sulphonic acid (3-APS) and baclofen on spontaneous, electrically-induced and propulsive motility were investigated in rabbit distal colon. 2. In unstimulated longitudinal (LMPs) and circular muscle strip preparations (CMPs) 3-APS (10-200 microM) and GABA caused a clear-cut relaxation susceptible to desensitization. Baclofen (10-200 microM) caused relaxation in a minority (30%) of preparations. The 3-APS response was sensitive to tetrodotoxin (TTX; 1 microM), SR 95531 (a novel competitive GABAA-receptor antagonist) (10 microM), picrotoxinin (30 microM), and insensitive to hyoscine (1 microM) and to a combination of prazosin (1 microM) and propranolol (1 microM). The baclofen response was antagonized by 5-aminovaleric acid (DAVA, 500 microM), TTX and hyoscine and resistant to GABAA-receptor and adrenoceptor blockade. GABAA-receptors were therefore associated with non-adrenergic non-cholinergic (NANC) inhibitory nerve activation while GABAB-receptors were involved in depression of cholinergic tone of smooth muscle. GABA (10-200 microM) elicited both above mentioned effects. 3. In LMPs, baclofen (10-200 microM) dose-dependently inhibited submaximal responses to both cholinergic and NANC inhibitory nerve stimulation. This effect was resistant to SR 95531 and picrotoxinin and prevented by DAVA and baclofen desensitization. GABA (10-200 microM) mimicked the action of baclofen. GABA inhibitory effects persisted in the presence of GABAA-receptor blockade. 4. In segments of distal colon, GABA and baclofen (1-200 microM), but not 3-APS (1-200 microM), dose-dependently decreased the velocity of propulsion of an intraluminally-distended balloon. This effect was antagonized by DAVA and GABA or baclofen desensitization and resistant to SR 95531 and picrotoxinin. These antagonists per se had no effect on propulsion. In preparations in which propulsion was slowed by hyoscine (1 microM), baclofen caused no consistent further depression of propulsive activity. 5. Our results show that GABAA- and GABAB-receptors are present in rabbit colon. GABAA-receptor stimulation activates NANC inhibitory nerves without apparently affecting propulsion. GABAB-receptors are associated with a reduction of neural (mainly cholinergic) activity subserving muscular tone and peristalsis and appear to be located on both cholinergic and NANC inhibitory nerves. However, the persisting propulsive activity during suppression of GABAA- and GABAB-receptor function suggests that GABA in enteric neurones is not crucial for the neural circuitry subserving colonic peristalsis in this species.

Interpretation of drug levels in acute and chronic disease states

Serum drug concentration monitoring can be an invaluable aid to patient management, particularly in certain pathological conditions when individualisation of dosage is particularly critical. To be clinically useful, however, drug levels must be interpreted in the context of all factors that could influence the correlation between the concentration of the drug in plasma and the intensity of action. Several such factors may be operating in acute and chronic disease states. For example, a number of pathological conditions are associated with marked changes in the fraction of free, pharmacologically active drug in plasma and this will result in disruption of the normal relationship between total serum drug level and effect, as seen for phenytoin in uraemia. An altered response to a given serum drug level in disease states may also be caused by changes in tissue distribution, by abnormal accumulation of pharmacologically active metabolites in plasma or by changes in end-organ responsiveness. The latter are best illustrated by the altered sensitivity to digoxin in patients with various conditions, including hypokalaemia and thyroid disease. In addition to the factors listed above, consideration should also be given to potential interactions with concomitantly used drugs and to the possibility of analytical errors, especially in view of the evidence that the performance of otherwise reliable drug assays may be grossly impaired in certain diseases (e.g. uraemia), due to abnormal plasma composition and/or accumulation of interfering metabolites. In view of these complexities, a correct interpretation of serum drug levels requires a good knowledge of clinical pharmacology and a close collaboration between physician and laboratory. In any case, serum drug concentrations, like other laboratory tests, are not a substitute for careful patient observation, and any decision about drug treatment should be primarily based upon evaluation of the clinical state and, whenever possible, direct measurement of drug effects.

Effect of chronic anticonvulsant monotherapy on lymphocyte subpopulations in adult epileptic patients

Sixty-five patients undergoing long-term monotherapy for at least 3 months with phenytoin, carbamazepine or phenobarbital were screened for lymphocyte and immunoglobulin abnormalities. In 57% of patients the duration of therapy was longer than 12 months. The control subjects were matched for sex and age and none of them was taking drugs. The average serum immunoglobulin (IgG, IgA, IgM) values did not differ in control and patient groups. A significant decrease of OKT4+ cells was seen with all drugs, while other lymphocyte subpopulations were differently affected depending on the drug used. It is concluded that long-term single-drug treatment with phenytoin, carbamazepine and phenobarbital exhibits immunosuppressant effects through a complex action which involves more than one lymphocyte subpopulation. Moreover, the possible interference of the disease state with the immune functions of epileptic patients is discussed.

Transmission in vitro of hepatitis C virus from persistently infected human B-cells to hepatoma cells by cell-to-cell contact

Virus cell-to-cell spread has been reported for many different viruses and may contribute to pathogenesis of viral disease. The role played by cell-to-cell contact in hepatitis C virus (HCV) transmission was studied in vitro by cell co-cultivation experiments. A human lymphoblastoid B-cell line, infected persistently with HCV in vitro (TO.FE(HCV)), was used as HCV donor [Serafino et al., 2003]; recipient cells were the human hepatoma HepG2 cell line. Both cell types were co-cultured for 48 hr to allow the cell-to-cell contacts. The hepatoma HepG2 cells are not permissive to free-virus infection, but they were infected successfully using TO.FE(HCV) cells as source of virus. The kinetics of viral RNA synthesis and the percentage of infected cells were compared in cell-mediated-and cell-free-viral infection. After co-cultivation, a consistent proportion of hepatoma cells replicated HCV and stably expressed viral antigens. Virus produced was infectious as demonstrated by the ability to reinfect fresh B-cells. This cell model shows that permissiveness to HCV infection can be achieved in vitro in non-permissive hepatoma cells by direct cell-to-cell contacts with infected human B-cells. This mechanism of virus spread may also play a pathogenic role in vivo.

Changes in sensitivity to the inhibitory effects of adrenergic agonists on intestinal motor activity after chronic sympathetic denervation

The concentration-effect relationships of adrenergic agonists in inhibiting muscular tone, carbachol-induced contraction of circular muscle strips and nerve-mediated motor activity during the peristaltic reflex have been studied in intact and sympathetically denervated preparations of isolated guinea-pig colon. The order of potencies of adrenergic agonists was different for muscular and nerve-mediated effects, being clonidine greater than noradrenaline greater than methoxamine greater than isoprenaline for the inhibition of peristalsis and isoprenaline greater than noradrenaline greater than methoxamine greater than clonidine for the relaxation of circular muscle. Denervation supersensitivity was specific for the adrenergic agonists and developed both to the muscular and nerve-mediated effects, involving both alpha and beta receptors. The degree of potentiation was similar for noradrenaline and isoprenaline when measured for the muscular effects but was significantly higher for noradrenaline than for isoprenaline or methoxamine when measured for peristalsis inhibition. No potentiation could be observed for papaverine and for the muscular effects of methoxamine and phenylephrine. The increase in potency of noradrenaline ranged from a 26-fold increase for the inhibition of propulsion velocity to a 2.5-fold increase for the inhibition of carbachol-induced contraction. A much narrower range was observed for isoprenaline. Potentiation could also be observed for the inhibitory effect of noradrenaline on acetylcholine release. Clonidine was the most potent agonist against peristaltic reflex and the weakest agonist in relaxing circular muscle. Denervated preparations became subsensitive to the inhibitory effect of clonidine on peristaltic reflex. The potency of clonidine relative to noradrenaline was 488 in intact preparations and only 3.1 in denervated organs.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum albumin in Hodgkin's disease

Serum albumin levels were measured by electrophoresis in 552 evaluable patients with Hodgkin's disease. Determinations were made on all patients at onset, on 224 after induction therapy and on 78 in relapse after remissions of variable length. At onset a discrete hypoalbuminemia was evident, inversely related to stage and more marked in symptomatic cases and elder patients. Little or no differences in albumin levels were found with relation to histologic subtypes, sex and presence of weight loss or hepatic damage. Posttherapeutic normalization of serum albumin occurred only after achievement of complete remission and failed after partial remission, while a new clear decrease became evident in relapse. On the basis of 799 albumin measurements during active disease and in remission, the albumin/alpha 2-globulin ratio demonstrated a clear and useful clinical advantage over either albumin or alpha 2-globulin fractions alone as indicator of active disease and relapse. If defective synthesis is the most accepted mechanism for hypoalbuminemia in Hodgkin's disease, these results suggest a casual factor somehow related to the tumoral mass.

Reduction of phenytoin clearance caused by cimetidine

The effect of cimetidine on the disposition kinetics of phenytoin was investigated in 7 healthy volunteers. Each subject received a single intravenous dose of phenytoin on two occasions, in the control state, and during concurrent treatment with cimetidine 1 200 mg/day for 6 days. A slight but statistically significant decrease both in the rate of elimination and total body clearance of phenytoin was observed during the administration of cimetidine. The effect is probably due to inhibition of metabolism.