BMSC5305

Integrative Biomedical Sciences V: Pharmacology

Absorption, Distribution, Metabolism and Elimination (ADME)

lecture by Dr. John Schetz

This presentation is intended for use by students enrolled in the course. Before sharing the format and/or content of these slides, prior written consent from the course instructor is required.
Copyright 2011-2012, Dr. John A. Schetz

Overview of Pharmacological Concepts and Dr. Schetzs part of the Course

Lectures 1-5
Figure adapted from Basic & Clinical Pharmacology, 11th Ed, by Katzung, Masters & Trevor, McGraw Hill, 2009.

Lectures 6-10

Learning Objectives for Lecture 1, 2 & 3

Pharmacokinetics: Absorption, Distribution, Metabolism and Elimination (ADME)
1. Define the term pharmacokinetic as well as details related to its component parts Absorption, Distribution, Metabolism, Excretion (ADME). 2. Describe factors that influence drug absorption, distribution, metabolism and excretion. Be able to list generalizations and explain their significance. 3. Explain the utility of the Henderson-Hasselbalch equation and be able to use it to calculate the ratio of charged to uncharged form of drug at a given pH. 4. Be able to recognize and define terms used to describe different routes of administration.

What is pharmacokinetics (PK)?

Pharmacokinetics is what the body does to drugs, while pharmacodynamics is what drugs do to the body.
The components of the pharmacokinetic response have the blood stream as a reference point and can be categorized as: Absorption movement of drug in to blood stream Distribution drug leaves blood stream and deposited in to tissues/organs Metabolism - drug is degraded or modified (often occurs in the liver), or drug is excreted (often occurs in the kidneys) Elimination changed or unchanged drug is removed from blood stream Note: The focus of PK (or its context) is the concentration of drug in blood plasma, which is a function of ADME

Some Routes of Administration

ENTERAL via gastrointestinal tract (mouth to rectum)
oral (per os from latin by way of mouth, p.o.) swallowed (most drugs) rectal suppository (e.g., marinol) sublingual - under the tongue (e.g., nitroglycerin), sublabial between lip and gums, subbuccal between check and gums, inhalation into the lungs

PARENTERAL via a non-enteral route (often means injected)

intravenous (i.v.) into the vein (e.g., heparin, insulin) subcutaenously (s.c.) under the skin intramuscular (i.m.) into the muscle intraperiteneal (i.p.) into the peritoneum (body cavity) (e.g.chemotherapeutics) intracerebroventricular (i.c.v.) into the cerebral ventricles Others: intranasal into the nose, intraotic into the ear, intraocular into the eye, etc.
Note: s.c. and i.m. bypasses epithelial barrier (tight junctions) leading to easier absorption via spaces between capillary endothelial cells, which is in contrast to enteral and transdermal routes. For instance, rectal, i.v., i.m., inhalational, intranasal nasal, sublingual and transdermal will all allow absorption directly into systemic circulation thus avoiding first pass (metabolism) effect in the liver.

Factors related to drug absorption

1.) The term absorption relates the site of administration of drug prior to its reaching the blood stream 2.) Requires crossing one or more cell/membrane layers so is applicable to all forms of administration EXCEPT for intravenous because this route is directly into the blood and for topicals because this is directly onto the target organ .
Note: diffusion flux is proportional to barrier surface area (& drug concentration) such that greater surface area leads to greater flux. logP is water:octanol partitioning coefficient and is a measure of passive diffusion across lipid membranes

More factors related to drug absorption

Drugs cross cell membranes by diffusion or transport 1.) passive diffusion (most drugs) A.) aqueous diffusion though pores for hydrophilic drugs if small (typically M.W. = 100-200 g/mole) B.) lipid diffusion for lipophilic drugs (logP values predict) 2.) transport (some drugs) carrier-mediated C.1.) facilitated diffusion no direct energy required, moves along concentration gradient only C.2.) active transport requires energy (e.g., ATP) D.) endocytosis-exocytosis requires energy
For example a tight junction between cells

Lumen is intravascular space Interstitium is extravascular space or space surrounding tissues the site of edema.

Figure adapted from Basic & Clinical Pharmacology, 11th Ed, by Katzung, Masters & Trevor, McGraw Hill, 2009.

Drug absorption can be reversed

Some absorbed drugs can be transported from the blood back into the small intestines (lumen blood) by the P-glycoprotein (Pgp) efflux transporter located in intestinal epithelial cells. Pgp thus serves a detoxifying role including chemotherapy drugs. The P stands for permeability. Pgp is also known as multidrug resistant protein 1 (MDR1). Grapefruit and orange juice inhibit Pgp with a potency that is substrate (i.e., drug) specific. Other drugs such as erythromycin and propranolol also inhibit Pgp.
Note that grapefruit juice also irreversibly inhibits the drugmetabolizing enzyme cytochrome CYP3A4, which limits the intestinal absorption of a number of drugs.

pH is one factor affecting (passive) absorption by affecting a drugs charge state

Non-ionized drugs are uncharged and thus passively diffuse across lipid membranes: in the case of weak acids (H+ + A- HA) the protonated form is uncharged while the opposite is true for weak bases (B + H+ BH+). Protons are hydrogen ions (H+). Charged drugs of significant size (>100-200 g/mole) and low lipophilicity do not passively diffuse across membranes.

Figure adapted from Pharmacology, 3rd Ed, by GM Brenner & CW Stevens, Elsevier, 2010.

The Henderson-Hasselbalch Equation

Ratio of ionized to non-ionized state affects absorption (distribution and elimination) rates. The HendersonHasselbalch equation is used to calculate the ratio of these two states.
Protonated base (charged)

Protonated acid (uncharged)

crosses membrane

The Henderson-Hasselbalch Equation

crosses membrane

log

( [non-protonated form] ) = pK - pH
[protonated form]
a

Figure adapted from Pharmacology, 3rd Ed, by GM Brenner & CW Stevens, Elsevier, 2010.

Note: in chemistry notation brackets [ ] means concentration of. The pKa is a physical property of a drug and is defined as the pH at which there are equal amounts (half and half) of the protonated and non-protonated form of the drug.

Example of how to use the Henderson-Hasselbach equation

A new fast dissolving film for sublingual application is being developed for the antipsychotic drug haloperidol. Haloperidol is weakly basic and has a pKa = 8.30 and saliva has a pH = 6.4. Calculate the ratio of protonated/non-protonated haloperidol in the mouth?
log

( [non-protonated form] ) = pK - pH
a

[protonated form]

This nitrogen is protonatable which will impart a +1 charge

log

( [non-protonated form] ) = 8.3 6.4

[protonated form] [non-protonated form]

[protonated form]

Haloperidol

= antilog (1.9) 101.9 = 79.4 Note: antilog 10x

Thus the protonated form (in this case the base form) of haloperidol predominates by a factor of ~79 at pH = 6.4. Why then is haloperidol readily absorbed? Based on charge character alone, would it be more or less likely for haloperidol to be absorbed from the mouth or gut? Why?

Practical considerations related to drug ionization state and absorption

Drugs that are relatively weak acids (pKa = 3-5) are better absorbed from the stomach than those that are relatively weak bases (pKa = 8-10) because both will be in their largely protonated forms due to the low pH of gastric juices, but for the weak acid the non-ionized (uncharged) form predominates facilitating its passive (lipophilic) diffusion across membranes.
The intestine has a higher pH so a much greater proportion of a weak acid will be in the ionized form suggesting lower absorption from the intestine, yet in actuality more is absorbed than from the intestine than the stomach because of the greater surface area of the stomach.
Tissue Fluid Aqueous humor Blood (arterial) Blood (venous) Blood (maternal umbilical) Cerebrospinal fluid Duodenum Intestine (microsurface) Lacrimal fluid (tears) Milk (breast) Muscle (skeletal) Nasal secretions Saliva Stomach Sweat Urine (female) Urine (male) pH 7.21 7.40 7.39 7.25 7.35 5.5 5.3 7.4 7.0 6.0 6.0 6.4 1.0-3.5 (closer to1) 5.4 5.8 5.7

What is Drug Distribution

The term distribution relates to the movement of drug from blood circulation into cells or interstitial fluids. Distribution of most drugs throughout body water is not uniform.
An exception is for the anti-manic drug lithium which is a small monovalent cation that is initially well distributed in body water and then later becomes somewhat sequestered inside cells containing sodium channels (since channels recognize it as sodium while ionic pumps do not so it gets trapped inside).

Factors related to Drug Distribution I

Passive diffusion or transport across membranes
a.) drug can be transported into liver where metabolism occurs b.) drugs can be transported from the blood back into the small intestines by the P-glycoprotein (Pgp) efflux transporter. c.) lipid solubility is a major factor governing passive diffusion of most organic drugs and thus distribution into the brain due to the blood-brain-barrier (BBB) similar to the passive diffusion across the gut-blood barrier. The BBB is composed of capillary endothelial cells ensheathed by astrocytic glial end feet. Drug size (on a molecular level) - very large molecular complexes such as the anticoagulant heparin (a sugar polymer) is largely confined to blood plasma. Note that heparin must be injected i.v.

Factors related to Drug Distribution II

Binding to Plasma Proteins
a.) virtually all drug are bound to some extent (10-99%) to plasma albumin, lipoproteins, -globulins and glycoproteins: acidic drugs prefer albumin and basic ones prefer -globulins and glycoproteins. An exception is the anti-mania drug valproate which is largely bound to plasma fatty acids. b.) because plasma protein binding is reversible and saturable one drug can displace another at high enough concentration. This is one example of a drug-drug interaction. c.) only free drug in plasma (that not bound to plasma proteins) can distribute into cells and interstitial fluids. A steady-state dynamic concentration gradient exists such that as free drug distributes protein-bound drug is release from plasma proteins to replace the free pool until the drug is completely distributed. d.) albumin is the major plasma protein thus conditions such as hypoalbuminea thus can affect drug distribution properties.

What is blood plasma?

Plasma is blood lacking red and white blood cells. Plasma typically represents about 55% of the volume of blood. Plasma is prepared by centrifugation which pellets out the red and white blood cells.
Whole blood Blood Components

Plasma (a.k.a. serum)

centrifugation

White Blood cells and Platelets Red Blood cells

Factors related to Drug Distribution III

Blood Flow
a.) the rate of drug distribution is directly proportional to cardiac output. Thus, drugs distribute more rapidly (and have a faster onset of action) in more highly perfused tissues such as brain, heart, liver and kidney. Skin, fat and bone are the least perfused tissues. b.) diabetes, atherosclerosis, hypertrophic cardiomyopathy reduce blood flow while excessive caffeine and marijuana use increase it.

TAKE A 5 MINUTE BREAK

Drug metabolism/biotransformation
Drug metabolism/biotransformation is one of the two ways drugs are eliminated from the body; the other is excretion. Often drugs must be biotransformed before they are effectively excreted.
A large array of enzymes metabolize drugs and toxins (collectively xenobiotics or substances foreign to the body) As a general rule, drug metabolites have increased water solubility (so that they can more readily be excreted By which organ?) which can take the form of conjugation of polar groups (e.g., glycuronidation or sulfination). There are two biotransformation phases named phase I and II.

Most drug metabolites are inactive

However, there are a number of important exceptions to this and can affect their distribution and rates of elimination (clearance).
1.) many benzodiazepines (e.g., diazepam) have active metabolites which prolongs their half-life 2.) glucuronidated morphine is more potent than morphine. 3.) the antipsychotic drug loxapine is metabolized to the antidepressant drug amoxapine. 4.) the tricyclic antidepressant imipramine is metabolized to desipramine which still has antidepressant activity.
Note: To improve absorption some drugs are made as prodrugs which are convert once absorbed: dipivefrin an antiglaucoma drug converted to epinephrine by corneal enzymes or the antihypertensive ACE inhibitor enalapril that is converted by liver esterases to its active form enalaprilat. Codeine is converted by liver oxidases to the analgesic morphine.

The first pass effect

Metabolism that occurs prior to entering systemic circulation is called the first pass effect.
Drug absorbed from the gut pass through the liver (via the portal vein) prior to reaching systemic blood circulation, which in many cases results in significant hepatic metabolism. This lowers the drugs bioavailability. It follows then that liver disease, like hepatitis, can affect bioavailability. Unless specifically noted the first pass effect is meant to refers to the passage through the liver via oral administration, but it can be metabolism that occurs via passage through any tissue and other routes.
Note: although not common and not usually extensive, some metabolism can occur in blood plasma but this is not referred to as a first pass effect because it is occurring within the blood circulation.

Phase I Biotransformation
Phase I enzymes often modifies drugs in such a way that they can be further modified by phase II metabolism.
Types of phase I reactions: 1.) oxidative except for the dealkylation reactions, the addition of an oxygen to the drug occurs: hydroxylation, deamination, N- or S-oxidation. Most common. The relevant enzymes are sometimes cytoplasmic but mostly cytochrome P450s in liver microsomes (endoplasmic reticulum fraction). Need energy too as NADPH. 2.) hydrolytic cleaves ester and amide bonds via hydrolysis (converts ketos to carboxylic acids). 3.) reductive nitro or nitrate reductase action; gets rid of an NO2 moiety. By far least common.

Phase I: Oxidative Reactions (a.k.a. CYP P450 monooxygenase system)

The hydroxylation and dealkylations are the most common of the oxidative reactions. There are numerous CYP isozymes with various isoforms of each but the majority of drugs are metabolized by CYP1, CYP2, CYP3 family. CYP3A catalyzes over half of all microsomal drug oxidations. For this reason, making a new drug that is metabolized by CYP3A is considered a liability due to the potential for drug-drug interactions (in this case two or more drugs competing for metabolism by CYP3A).
Note: some drugs induce the expression of CYPs and thereby affect the rate of metabolism of other drugs.

Phase II Biotransformation
Phase II enzymes conjugate hydrophilic acetate, glucurononate, sulfate or glycine moieties to drugs. The purpose is to make the drugs more water-soluble and consequently more readily excreted. Glucuronidation is the most common.
1.) Phase II enzymes in liver and other tissues. 2.) Most enzymes are located in the cytoplasm. The exception is for glucuronosyltransferase which located in the liver microsomal fraction. 3.) By and large Phase II conjugated drug metabolites are inactive (an exception is for morphine whose glucuronidated metabolites is not only active but more potent than the parent compound). 4. All the Phase II enzymes are _____tranferases (e.g., sulfotransferase)

Generalizations about drug metabolism

Phase I pathways

CYP3A4/5 and UGT, are involved in the metabolism of more than 3/4 of all drugs in use Many drugs are metabolized by two or more of pathways

Phase II pathways

CYP - cytochrome P450 DPYD - dihydropyrimidine dehydrogenase GST - glutathione-S-transferase NAT - N-acetyltransferase SULT - sulfotransferase TPMT - thiopurine methyltransferase UGT - UDP-glucuronosyltransferase.
Figure adapted from Basic & Clinical Pharmacology, 11th Ed, by Katzung, Masters & Trevor, McGraw Hill, 2009.

Learning Objectives for Lecture 3

Pharmacogenetic and Drug Elimination/ Excretion and Clearance
1. Define pharmacogenetics and explain its application to pharmacokinetics. Be prepared to describe specific examples in detail. 2. Explain in detail the process of drug excretion/elimination and reabsorption via the kidneys and the liver and the factors that influence these processes. 3. Compare and contrast saturable and flow-dependent elimination process and be able to provide examples of two drug that undergo each process. 4. Define the term clearance and be able to calculate renal and hepatic clearance of drugs.

Pharmacogenomics/ Pharmacogenetics
Pharmacogenomics is the study of how genetic variation affects drug responses with the focus typically being on single nucleotide polymorphisms (SNP) which can affect gene expression when present in non-coding regions or a proteins activity when expressed in coding regions. The value lies with the idea that specific (typically ethnic) populations have similar genetic variations that can be exploited to a priori evaluate a drugs potential toxicity or efficacy. The hope is to tailor drugs for individual genetic profiles.

Pharmacogenomics/Metabogenomics
Common examples related to metabolic enzymes:
1.) acetyltransferases slow metabolizers are at risk of toxicity from sulfonamide antibiotics, antiarrhythmic procainamide, antihypertensive hydralazine and antitubercular isoniazid. >80% of middle eastern populations are slow metabolizers. 2.) oxidases a.) 10% of Caucasians have the poor metabolizing CYP2D6 variant preventing them from converting codeine to morphine. b.) rapidly metabolizing CY2C19 variants degrade omeprazole so quickly that larger doses are needed. c.) slowly metabolizing CYP2C9 variants degrade warfarin less quickly so lower doses needed in Caucasians.

Case study of warfarin pharmacogenetics

Warfarin is a blood anticoagulant acting essentially as a vitamin K antagonist by irreversibly inhibiting vitamin K epoxide reductase (VKORC1), an enzyme critical for vitamin K recycling. In short, vitamin K is a key mediator of the gamma-carboxylation of glutamates present in coagulation factors and preventing its vitamin K recycling interferes with activation of blood clotting.
The clinical finds are that on average, African populations require higher doses or warfarin to achieve the recommended prothrombin ratio between 2-3, than do other ethnic populations particularly Asians

Dang et al. (2005) Ann. Pharmacotherpy 39:10081012.

What accounts for ethnicity-dependent doses for warfarin?

1.) METABOLISM: Slowly metabolizing CYP2C9 variants degrade warfarin less quickly so lower doses needed in Caucasians, but this does not explain why Asian (2-5%) populations need lower does than African (1-2%) and Caucasian populations (5-18%). 2.) OTHER: There is a strong linkage between a VKORC1 variant (-1639 GA) in the non-coding upstream region (What will this affect?) and the need for lower doses. Turns out that Asians are predominantly (90-95%) AA homozygotes, Caucasians are predominately AG heterozygotes (35Johnson (2008) 45%) Circulation and Africans are predominately (90-92%) GG 118:1383-1393

Drug elimination/excretion
Drug excretion is one of the two ways drugs are eliminated from the body; the other is metabolism. Excretion defined as remove of drug (or its metabolites) from the body. Often this means from body fluids and typically this means via the kidney as a product of urine. However, other routes of excretion occur inducing via the feces, bile, sweat, tears, breast milk and exhalation.

Factors related to Drug Excretion

Excretion of exogenous and endogenous substances via the kidneys follows the process glomerular filtration, active tubular secretion, and passive tubular reabsorption (back into blood supply). About 20-25% of cardiac output passes through the two kidneys.
Schematic of the kidney at molecular mechanistic level
Back to blood
Filtration Secretion Reabsorption

plasma protein-bound drug free drug

From blood
Excretion (urine)

Figure adapted from Pharmacology, 3rd Ed, by GM Brenner & CW Stevens, Elsevier, 2010.

Excretedkidney = (Filtered + Secreted) Reabsorbed

Factors related to Drug Excretion

Glomerular Filtration free drug enters renal tubule; protein-bound drug then does not undergo this step because proteins cannot or only slowly enter. Active Tubular Secretion particularly weak acids and bases are actively transported (secreted) from proximal tubular cells. Not affected by protein-bound drug. Passive Tubular Reabsorption like other types of passive diffusion drug lipophilicity is a key factor; more polar metabolites are less well reabsorbed. It follows then that uncharged forms of weak acids and bases are better reabsorbed so renal pH is key.
How can renal pH be exploited in drug/poison overdose?

Factors related to Drug Excretion

Biliary Excretion: Excretion of drugs into bile (the bile duct connects the liver to the intestine) is not uncommon for amphipathic drugs with M.W. > 300 g/mole and phase II metabolites (especially glucuronated metabolites). Examples, include glucuronated and sulfonated steroid metabolites. Once drugs in bile move into the intestines via the bile duct they may be partly reabsorbed via a process known as enterohepatic cycling. Intestinal flora may reverse the conjugation thereby facilitating reabsorption of parent compound.
Blood flow to liver is ~20-25% of total cardiac output. Liver has two blood supplies: 1/5 from hepatic artery and 4/5 from portal blood
Enterohepatic cycling

Figure adapted from Pharmacology, 3rd Ed, by GM Brenner & CW Stevens, Elsevier, 2010.

Minor routes of Excretion: While a small component of the excretion of some drugs many be in the saliva or sweat.
Note: drug levels of saliva often represent amounts present in inside the cells of target tissues and thus has practical value in clinical studies of new drug PK.

Renal Excretion, Clearance and Related Measures

Notice the correspondence between these new relationships and ones we have already learned (outlined in yellow boxes). Since many drugs are cleared primarily by the kidney the rate of clearance by the kidney is often essentially synonymous with the rate of drug elimination
Rate of Elimination = Clearancekidney = Excretion Rate / Plasma [Drug]total
Excretionkidney Rate = (Filtration Rate + Secretion Rate) Reabsorption Rate = [Drug]urine x Flow Rateurine

log(Reabsorptionkidney Multiplier) = log

( [non-protonated form] )

[protonated form]

= pKa - pH

Factors related to Drug Elimination/Excretion

Capacity Limited Elimination: Drug clearance depends upon drug concentration. It is also known as saturable or dose-dependent or non-linear (i.e., Michaelis-Menten) elimination. Examples include ethanol, aspirin and phenytoin. The reason for this is when doses exceed the elimination capacity and a steady-state cannot be achieved, thus in these case clearance has no real meaning. Blood flow-dependent Elimination: In this case most of the drug is eliminated by first pass through the eliminating organ so blood flow is the primary factor related to their elimination. Such drugs are called high extraction drugs. Examples of hepatic high extraction drugs include morphine, haloperidol, verapamil, tricyclic antidepressants, propranolol, while low extraction drugs include diazepam, phenytoin, warfarin.

Practical applications related to flowdependent elimination

Blood flow-dependent Elimination is a major contributor to the clearance of high extraction drugs. Recall that at rest 20-25% of cardiac output goes to liver and kidney (both combined) and that the liver is typically the primary site of metabolism. 1.) There can be considerable individual variability in bioavailability of a drug with a high extraction (ratio) due to differences in liver function and blood flow. 2.) For a variety of reasons including reduced cardiac output and reduced mass or function, renal and hepatic blood flow can be reduced in the elderly requiring dosage adjustments for high extraction drugs.

More on Drug Clearance (Cl)

Clearance is a rate constant representing the rate of drug elimination from the body; it is defined as the volume of body fluid from which the a drug is removed per unit time.
RENAL CLEARANCE = Excretion Ratekidney / [Drug]plasma

If a drug is primarily eliminated by glomerular filtration (and little or no tubular secretion or reabsorption occurs), then its clearance rate will be similar to the protein creatine or ~100 mL/min. Lower rates suggest high plasma protein binding or passive tubular reabsorption, while higher rates suggest significant elimination by tubular secretion.
HEPATIC CLEARANCE Blood Flowhepatic x ([Drug]venous [Drug]arterial)

This estimate is used because include additional factors such as biotransformation and biliary excretion.

Learning Objectives for Lecture 4

Application of pharmacokinetic concepts: volume of distribution, bioavailability, Cmax, Tmax, AUC, minimum effective concentration, duration of action.
1. Define graphically and in writing the terms Cmax, Tmax, AUC, minimum effective concentration and duration of action. 2. Explain the meaning of a two compartment model in the context of the pharmacokinetic behavior of a drug. 3. Define the terms volume of distribution and bioavailability, describe factors influencing them and explain the practical use of these terms. Be prepared to provide a detailed and properly labeled graphical explanation when appropriate. 4. First define the term loading dose and then calculate the loading dose of a drug.

Modeling Pharmacokinetic Behavior

A minimum of a two-compartment PK model is need for most drugs, where blood is the one compartment and distribution into tissues is the other compartment.
kabsorption e.g. GUT absorption
readsorption

Compartment 1

kelimination

Blood
Distribution

elimination
readsorption

e.g. URINE

The elimination half-life (t) can be estimated from these models where k values are rate constants.

kdistribution

Compartment 2

Tissue

Graphing of pharmacokinetic terms

Plasma Drug Concentration Curve (single oral dose)
oral dosing

Figure adapted from Pharmacology, 3rd Ed, by GM Brenner & CW Stevens, Elsevier, 2010.

MEC is the minimallyeffective concentration (for a therapeutic effect) and the time this level of drug is sustained or exceeded is the Duration of Drug Action. AUC is area under the curve. Cmax is the maximal concentration achieved in plasma and Tmax is the time at which this occurs.

Graphing of pharmacokinetic terms

Cmax (i.v.)

Drug Bioavailability Curve

AUCoral < AUCIV so F < 1.0

Figure adapted from Pharmacology, 3rd Ed, by GM Brenner & CW Stevens, Elsevier, 2010.

Cmax (oral)

Tmax (i.v.)

Tmax (oral)

i.v. dosing oral dosing

Bioavailability represented by the letter F is the fraction of drug reaching system circulation in active form by any route of administration compared to (divide by) an i.v. route of administration

Factors affecting drug bioavailability (F)

1.) An i.v.- administered drug has 100% bioavailability, thus administration by any other route will result in F < 1.0 except in the extremely rare case where a drug is immediately absorbed in its intact state. 2.) Anything that affects the rate/extent of drug absorption of parent compound will affect bioavailability including a.) Rate/extent of tablet disintegration and drug dissolution b.) Gastric contents/pH c.) Gut/liver enzymes (esp. CYP3A4)

Volume of distribution (Vd)

The (apparent) volume of distribution is a conceptual term that describes how sticky (usually how lipophilic) a drug is or how much drug sticks to tissues into which it is distributed: it is a measure of distribution.
Vd may exceed the volume of the body, since it relates to the volume apparently needed to homogenously contain a quantity of drug at the concentration found in plasma. In other words, it is the volume that would be needed to dissolve a drug such that it has the concentration found in plasma and describes the relationship between administered dose of a drug and the concentration measured in plasma.

Volume of distribution (Vd): a visual example

Add volume to wash out drug stuck to the glass of the beaker (e.g., body) Administer Drug Drug Absorbed & Distributed water 1x 2x water 3x water No More Drug Stuck in Body (wash out complete)

drug

Body

blood

copyright Dr. John A. Schetz, 2012

This drug has a Vd = 4x the volume of body water (or ~2.8 L/kg)
Note: In total 3 volumes were needed to completely rinse the drug off of side of the beaker

In this example, the drug is very lipophilic and thus sticks to lipophilic stores in the body and is washed out only after repeated washing (volumes).

Vd practical consideration
One way to think about Vd is that is describes how sticky a drug is to extravascular tissues (relative to the vascular compartment meaning blood or plasma). For instance, a sticky drug will have a lower concentration in plasma and thus a larger volume of distribution meaning it has a high concentration in extravascular tissue in other words it is not homogenously distributed between blood and (extravascular) tissues. The typical volume of body water is around 0.6 L/kg (0.5-0.7 L/kg) and the typical volume of just the vascular (plasma) compartment is 0.04 L/kg (about 2.8 L for a 70 kg person).

Typical body volumes

Table from Basic & Clinical Pharmacology, 11th Ed, by Katzung, Masters & Trevor, McGraw Hill, 2009.

Generalities related to the meaning of Vd

High Vd (> ~2 kg/L) means the drug is sticking to tissues and usually this means the drug is very lipophilic. What are the major lipophilic compartments in the body? It could also mean the drug is stuck/trapped inside cells (intracellular fluids), e.g., the intracellular pH is more acidic than plasma so weak bases are more charged and become trapped. Low Vd (< ~0.6 kg/L) meaning similar to plasma or extracellular fluid volume of the body means the drug is restricted to a particular body compartment . A drug can be restricted to the plasma compartment if it has high (plasma) protein binding for example. A Vd similar to total body water (< ~0.6 kg/L) usually means the drug is readily water-soluble and is distributed into intracellular fluids.

Empirical Determination (calculation) of Vd

Note: this is a log scale so straight line can be drawn for an exponential

C0 is an interpolated value and is the concentration of drug at time zero

Figure adapted from Pharmacology, 3rd Ed, by GM Brenner & CW Stevens, Elsevier, 2010.

If this data were for a 200 lb person (200 lbs x 0.4536 kg/lb = 90.7 kg) then the Vd = 1.10 L/kg. Thus, this drug has low to moderate Vd compared with total body fluid which is ~0.7 kg/L

Learning Objectives for Lecture 5

Application of pharmacokinetic concepts: zero-order and first-order elimination (clearance), halflife, loading and maintenance dose, single and multiple dosing, steady-state, and time course of drug effects
1. Compare and contrast zero-order and first order elimination processes including half-life values. Be prepared to provide a detailed and properly labeled graphical representations of each. 2. Explain the meaning of a drug steady-state and relate this to pharmacokinetic factors. 3. Compare and contrast intermittent and continuous dosing including the effect on plasma doses and dose fluxuation. 4. Define and calculate loading and maintenance doses. 5. Compare and contrast single and multiple dosing elimination kinetics. 6. Compare and contrast immediate, delayed and cumulative drug effects and provide specific examples.

Calculation of the Loading Dose of a Drug The volume of distribution (Vd) is a useful measure for calculating what dose of drug should be loaded in order to achieve a desired plasma concentration.
Drug Loading Dose = Vd x [drug]desired in plasma
If for drug A the Vd = 3.2 L/kg and the patient weights 65 kg and the desired plasma concentration of Drug A is 23 mg/L, then what loading dose of drug should be administered? Drug Loading Dose = Vd x [drug]desired in plasma = (3.2 L/kg x 65 kg) x 23 mg/L = 4784 mg or 4.78 g
Loading dose is also known as the priming dose. It is given to rapidly establish a therapeutically relevant drug plasma concentration. If a drug

Elimination for Single Dose Pharmacokinetics

The majority of drugs exhibit first-order kinetic of elimination meaning their rate of elimination is an exponential decay function (and is proportional to the plasma concentration of drug).
[Drug]plasma / time = -ke x ([Drug]plasma)n
First-Order
n exponent = 1

A few drug (e.g., ethanol) have zeroorder kinetics meaning that the rate of their elimination is constant (and is independent of the plasma concentration of drug).

Zero-Order
n exponent = 0

Figure adapted from Pharmacology, 3rd Ed, by GM Brenner & CW Stevens, Elsevier, 2010.

The rate of elimination elimination rate constant (ke) for first-order kinetics but it is for zero-order kinetics. The ke is the fraction of drug eliminated per unit time.

Calculating drug plasma concentration from dose and clearance for a drug with first-order elimination kinetics. The plasma concentration of a drug can be calculated from its dose and clearance if it has firstorder kinetics of elimination. Drug elimination half-life (t)and clearance (Cl) remain constant (so long as kidney and liver functional remain constant). This PK knowledge is useful as it allows for dose to be adjusted to achieve a therapeutic effect.
First-Order

Figure adapted from Pharmacology, 3rd Ed, by GM Brenner & CW Stevens, Elsevier, 2010.

Calculating other PK measure for a drug with first-order elimination kinetics

For a drug with first-order elimination kinetics, the drug elimination half-life (t) is the time needed to reduce the concentration of drug in plasma by half and it can be determined by a drug plasma concentration curve or from ke.

Ct = C0 x e(ke)(time)

Figure adapted from Pharmacology, 3rd Ed, by GM Brenner & CW Stevens, Elsevier, 2010.

t = log2 x ke = 0.693 x ke

1st t

2nd t

3rd t

Cl = (0.693 x Vd) / t and also t = (0.693 x Vd) / Cl

Many factors (such as disease and age) can alter Vd and/or Cl which will alter the t for a drug

since upon rearranging ke = 0.693/ t and Cl = Vd x ke

Calculating other PK measure for a drug with zero-order elimination kinetics

C For a drug with zero-order Zero-Order elimination kinetics, the rate of drug elimination is constant C and usually this is because the elimination process is saturated. This occurs for most doses of alcohol but can also occur at higher doses of 1st t 2nd t 3rd t other drugs such as aspirin or phenytoin. Also can occur in Note that t for a drug with cases of impaired kidney or zero-order elimination liver function such as in kinetics is not constant disease. though it is still
0 t
Figure adapted from Pharmacology, 3rd Ed, by GM Brenner & CW Stevens, Elsevier, 2010.

proportional to [drug]plasma

Continuous and Multiple Dose Pharmacokinetics

For drugs with first-order kinetics of elimination, a steady-state (plateau) will be reach if administered continuously or semi-continuously (intermittently) so long as the intermittent rate of administration not a lot less than 5x the rate of elimination. The steady-state is reached when the rate of administration is equivalent to the rate of elimination and since the rate of a first-order elimination is a constant and a function of the elimination half-life so too is the steady-state.
Since it takes approximately five half-lives for drug elimination to be essentially complete (i.e., 96.9% complete), it also takes five half-lives (5 x t) for steady-state to be reached.
Figure adapted from Pharmacology, 3rd Ed, by GM Brenner & CW Stevens, Elsevier, 2010.

Steady-state drug levels

Steady-state drug levels (steady drug concentration in blood plasma) depends upon the administered dose per unit time and the elimination half-life. For instance if either half-life or dose is doubled the steady-state level will double as well.
Figure adapted from Pharmacology, 3rd Ed, by GM Brenner & CW Stevens, Elsevier, 2010.

Double dose = double [drug]plasma

Double half-life = double [drug]plasma

Half-life is the time it takes to achieve 50% of the steady-state and also the time it takes to reduce drug concentration by 50% once at the steady-state

Continuous versus intermittent dosing

While the rate at which the steady-state is reached and the average plasma drug concentration is the same regardless of whether the drug is administered intermittently or continuously, the fluxuations in drug plasma concentration will vary.

Figure adapted from Pharmacology, 3rd Ed, by GM Brenner & CW Stevens, Elsevier, 2010.

Calculating the Maintenance Dose of a Drug

Maintenance dose is for establishing a specific steady-state concentration of drug in plasma. The maintenance is typically lower than the loading dose and is always in the context of repeated dosing. The intended frequency of dosing is an important parameter because fluxuations in [Drug]plasma will increase with longer dosing intervals.
At steady-state the rates of administration and elimination are equal

Figure adapted from Basic & Clinical Pharmacology, 11th Ed, by Katzung, Masters & Trevor, McGraw Hill, 2009.

Maintenance Dose = Rate of Administration x dose interval (amount) (amount/time) (time) Desired Rate of Administration = Rate of Eliminationsteady state = [Drug]steady-state (in plasma) x Cl

Time course of drug effects

Immediate Effects Drug effects are directly (but not linearly) related to plasma concentrations. This assumes that plasma concentrations are the same as/similar to target tissue concentration. If drug acts on CNS then brain The blue dashed horizontal line penetrance must be considered. represents the EC concentration
50
Figure adapted from Basic & Clinical Pharmacology, 11th Ed, by Katzung, Masters & Trevor, McGraw Hill, 2009.

The key relationship is that the concentration of drug exceeds or is equal to the drugs potency (EC50). This assume that a half maximal effect is sufficient to give a adequate therapeutic response. If the initial dose of the drug results in plasma concentrations well about the EC50 concentration then there will be immediate drug effects whose duration is then a function of the initial dose and the halflife of the drug.

Half Maximal Effect

EC50
Time (hrs)

Time course of drug effects

Delayed Effects There is a time lag between drug effects and drug plasma concentration. Most drugs fall into this category.
A delay of second to minutes is typically due to distribution from plasma to site of action/target tissue. An example would be i.v. injection of phenobarbital, which has a rapid onset but is not instantaneous. A delay of hours to days is typically due to protein turnover (new protein synthesis). An example would be warfarin which irreversibly inhibits vitamin K epoxidase the enzyme that (chemically reduces) reactivates vitamin K a co-factor in the -carboxylation of four blood clotting factors. Changes in coagulation (measured as prothrombin times) take 8-12 hrs the time it takes for the clotting factors to begin to significantly degrade (the blood clotting factor complex has a t = 14 hrs) A delay of weeks is typically due to compensatory changes in protein expression. An example would be antidepressants drugs which take 14-18 days to produce an antidepressant effect. Chronic down regulation of one protein may alter the expression levels of a different protein.

Time course of drug effects

Cumulative Effects There is a time lag between drug plasma concentration and biological effect related to dosing regimen. Drugs that produce a toxic effect related to xenobiotic growth are typically in this category, e.g., anti-cancer treatments.
For example, anti-cancer agents that irreversibly bind to DNA undergoing mitosis have as an effect the slowing of tumor growth. The cumulative effect over time may be the complete arresting of tumor growth. Other examples include antibiotics which are affecting the growth of bacteria.
Toxic side-effects of drugs might also fall into this category including aminoglycoside toxicity of the kidney (intermittent dosing saturates uptake into renal cortex limiting toxicity).

Time course of drug effects

Other Effects - A disconnect between drug plasma concentration or number of drug exposures and an effect.
(Acquired) Allergic reactions to drugs or chemical agents fall into this category in that only a low threshold dose is needed. Examples would include clozapine-induced agranulocytosis. Neuroleptic malignant syndrome is another example but in this case the effect is often occurs after only 1 or 2 doses. L-DOPA-induced tardive dyskinesia (drug-induced late-stage abnormal movements) falls into this category as the effects may persist (be permanent) even after the drug is removed. Desensitization or drug tolerance falls into this category as the magnitude of the effect decreases upon repeated exposure to drug.