Analyzing Drug Action in Humans Pharmacokinetics, Biotransformation Drug Safety

Drugs - Receptors
Nearly all drugs act via specific binding sites receptors Structural complexity, potent structureactivity relationship (enantiomers, strict structural requirements for activity, low dose required)
Exceptions are gas inhalation anesthetics and ethanol (large doses, no specific binding site, simple molecules, very little structural complexity)

Drugs - Receptors
Mimic or block actions of endogenous ligands such as:
Hormones Neurotransmitters Autacoids

Drugs - Receptors
Most are large proteins Ligand binding causes conformational change If accompanied by intrinsic activity = agonist If not accompanied by intrinsic activity = antagonist Partial agonists less efficient, conformational change, maximal effect of full agonist cannot be achieved

Receptor-Ligand Relationship
Most cells display very large numbers of receptors Only overall partial occupancy needed for full response
E.g.: 30 million ACh-receptors on skeletal neuromuscular junction, only 40,000 need to bind ACh for full contraction reserve receptors

Receptor-Ligand Relationship
Receptor number can change
Disease caused Age Genetic variation Chronic drug administration

Receptor binding
Studied in ligand binding assays Non-linear relationship of dose-response curves

Receptor-Ligand Relationship

Specific - Non Specific Binding

Dose Response
Assessment of the drugs effect
E.g.: pulse rate, blood pressure, urine production, pain relief, blood glucose levels, etc.. Maximum effect (!?) desired outcome Potency: Dose required to achieve desired effect E.g.: NSAID: Ibuprofen: 400 mg 3x daily; Diclofenac: 50 mg 3 x daily, Piroxicam: 20 mg 1 x daily

Dose Response

Measurements of Drug Response

In vitro
In isolated preparations (cells, tissues, organs)

In vivo
In the intact animal/human

Parameters measured
Chemical, physical, physiological

ED50 = dose at which 50% of Emax is reached ED10, ED25

Measurements of Drug Response

ED75/ ED25 measure of steepness of dose response curve Drugs with very steep dose response curve potential danger of over dosage Therapeutic Ratio: Indication of safety margin
LD50/ ED50 or LD25/ED75 Digoxin: 1.5; Aspirin 20, Penicillin G 60

Clinical Response
Ultimate objective of drug therapy? E.g. long term treatment of chronic diseases Long term outcome
E.g.: hypertension, reduction of development of chronic disease, or increased mortality Ultimate effect: not reduction of blood pressure rather prolonged, disease-free life Problem of long term monitoring of patient outcome

Factors Influencing the Action of Drugs

Drug delivery Distribution Drug Metabolism Excretion Pharmacokinetics Pharmacogenetics

Drug Delivery
Local (topical) systemic Drug Formulations
Tablets, capsules, solutions, suspensions (modified released products) Injectables, ointments, creams, suppositories, implants

Most common route of administration per os (oral)

Modified Release Tablet Oral Administration

Drug Delivery
Local application
Skin diseases (ointments, etc.) Eyes, nose, oral cavity, throat, rectum (suppositories), vagina Accompanied by various degrees of systemic absorption

Drug Delivery
Systemic application
Oral (gastro-intestinal tract) Sublingual (nitrates for angina pectoris) Parenteral (all routes not through GI-tract)
Intravenous Intra-arterial Subcutaneous Intramuscular Epidural Intraarticular

Drug Delivery
Systemic application
Rectal Nasal mucosa Inhalation

Drug Absorption
Drug molecules need to reach target via systemic circulation and diffusion as dissolved molecules Virtually all drugs are small MW (<1,000) organic compounds Acid/base properties Lipid solubility crucial for crossing cell membrane barriers (GI-absorption, blood brain barrier crossing)

pKa of Drugs & Ionization

pKa = acid constant

HA

H+

- Dissociation of an acid +A

Henderson Hasselbalch equation -] pka = pH + log [HA]/[A

If pKa = local pH drug is 50% ionized/nonionized (need non-ionized form to diffuse through membranes!) Rule of thumb: Acidic drugs are well absorbed from acidic environment (stomach), basic drugs from basic environments duodenum

pKa Values of Acidic & Basic Drugs

Dissolved Drug Distribution for an Acidic Drug

Dissolved Drug Distribution of a Basic Drug

Distribution
Compartments of the body
Size Blood flow pH Protein concentration Barriers

All effect drug concentration over time

Distribution
Once drug is in blood stream free to pass into interstitial space via filtration Plasma protein binding limits amount of free drug Acidic drugs albumin binding Basic drugs globulin binding Blood flow speed of distribution

Protein-Bound & Free Drug

Thiopental levels after i.v. inj.

Distribution
In suspected overdose:
Acidic drugs will accumulate in circulation (blood pH=7.4) Basic drugs will accumulate in the stomach (pH=2) Sampling for diagnosis!

Distribution
Barriers
Blood-brain b.: only permeable to lipid soluble molecules (unless inflamed)
No protein in CSF no protein binding of drug molecules

Placental b., Brest milk: Unless proven otherwise it must be assumed permeable to drugs!
Risk of fetal/newborn exposure to teratogens, toxic effects

Apparent Volume of Distribution

Dose administered resulting drug conc. in plasma E.g. for ethanol: equal to body water (ethanol is concentrated equally throughout body) For most basic drugs very high due to sequestering outside circulation (enrichment in specific organs (liver, muscle, fat, etc.)

Typical Values for Apparent Volume of Distribution

Drug Metabolism - Biotransformation

Phase 1
Oxidation, reduction, hydrolysis Via relative non-specific enzymes

Phase 2
Conjugation reactions Attachments of large groups
Sulfate, glucuronic acid, glutathione, acetate

Drug Metabolism
Several hundred isoforms of Cytochrome P450 oxidases Cause of large inter-individual differences in drug metabolism Enzymes can be induced
Drug interactions Liver major site of biotransformation Increased water solubility renal excretion

Many drugs (or other compounds) can induce/inhibit drug metabolizing enzymes

Oxidation of a Drug (here Hydroxylation)

Biotransformation of Diazepam (Valium)

Oxazepam R-OH conjugation with glucuronic acid elimination through urine

Enhanced water solubility

Drug Metabolism
Half life (t) - time after which plasma conc. has decreased to 50% of maximum (initial) Rule of thumb: after 5x t drug is completely eliminated (502512.56.253.125 %)
Virtually all drugs: First order kinetics of elimination: low concentration large number of metabolizing enzyme Exception: ethanol zero order high concentration low number of metabolizing enzyme (saturation)

Drug Plasma Concentration after Parenteral Administration (e.g. I.v.)

Drug Metabolism
Bioavailability
Actual achieved concentration after administration of a certain dose 100% by definition after i.v. injection <100% if processes compromise absorption (oral route, etc.), drug is rapidly degraded in GI-tract or at first pass through liver

Drug Plasma Concentration After Oral Administration

 Metabolite can be:

Inactive Still active Only active form (original drug: prodrug!)

Drug Metabolism

Drug Excretion
Some elimination via bile & feces, skin, lungs Most important: renal elimination
Affected by water solubility uncharged molecules becomes reabsorbed from primary filtrate Affected by urine pH Affected by urine flow rate

Pharmacokinetics
Considers overall absorption, distribution, metabolism & elimination One-compartment model
Analysis of plasma concentration after administration

Pharmacokinetics
Crucial for establishment of dose regimen How much? How often? Goal: Most often: create a relative constant steady state tissue concentration to achieve desired pharmacodynamic effect Absorption = excretion

Pharmacokinetics
Steady state rule of thumb:
After five administrations within five t steady state is reached 5.21

Sometimes loading dose to speed up process followed by maintenance dose

Drug Plasma Concentration of a Compound with a t1/2 of 6 hr administered every 6 hr

Pharmacokinetics
Age, Sex & Genetic Variations Fetus & premature infants
Usually less efficient metabolism Immature renal function

Children
More efficient metabolism than adults

Elderly
Chronic diseases, multi-drug use, less plasma protein, lean body mass decrease, decreased liver function

Drug Interactions
Chemical
Tetracycline/Ca++ in milk & supplements, etc. Levodopa/Fe++ in supplements & multivitamins

Pharmacokinetics
Protein binding competition Cardiodopa/levodopa (intentional interaction)

Pharmacodynamic
Anticoagulants/NSAIDs

Contraindication
Patient Condition prohibits use of drug
Patient with osteoporosis should not receive diuretics that cause loss of Ca++ Asthma patient should not receive Beta blockers causing potential bronchoconstriction

Role of Pharmacist (Pharmanet)

Computerized screen for drug interactions/ Contraindication based on disease & allergy profile (not computerized)

Drug Safety
Drugs are chemicals and all chemicals are potentially harmful New therapeutics need to be assessed thoroughly over long periods of time to minimize the risk/benefit ratio Very few disasters since introduction of modern Pharmacology:
Ethylene glycol solvent use in 1930s (ca. 100 fatalities), Thalidomide 1961 (ca. 10,000)

Adverse Reaction
A medication claimed to be free of adverse reaction is very suspicious to lack any therapeutic action unknown
Difficulties in tracing true causes of perceived adverse reaction
Onset, duration, other causes, other disease symptoms Acute vs. insidious adverse reaction Long term (cancer?) Scientific proof