Newer H2-receptor antagonists. Clinical pharmacokinetics and drug interaction potential

Since H2-receptor antagonists are widely and successfully used in the treatment of peptic ulcer, several alternatives to the standard agents cimetidine and ranitidine have been developed. Promising 'new' candidates might be famotidine and nizatidine. For proper selection of the appropriate drug, its pharmacokinetic properties and interaction potential should be known. All 'old' and 'new' H2-receptor blockers are eliminated relatively rapidly (t 1/2 ranges from 1.5 to 4 hours), mainly by the renal route (glomerular filtration and tubular secretion). They exhibit a linear disposition and their distribution is similar. Absorption is most complete for nizatidine, whereas famotidine demonstrates the lowest effective plasma concentrations. Since etintidine shares the same imidazole ring structure as cimetidine, it can also impair oxidative drug metabolism in the liver. In this respect, the non-interacting famotidine and nizatidine (like ranitidine) offer a definite advantage. Based on their very similar pharmacokinetic and interaction profiles, these 2 H2-receptor antagonists might be regarded as alternatives to the older drugs in this group, and at least some economic benefits might result from the competition they will provide.     

Inhibition of gastric alcohol dehydrogenase activity by histamine H2-receptor antagonists has no influence on the pharmacokinetics of ethanol after a moderate dose.

Ethanol undergoes gastric first pass metabolism by alcohol dehydrogenase (ADH). We have shown that cimetidine and famotidine both cause competitive inhibition of human gastric ADH in vitro. However, in a randomized 4-way cross-over study in 12 healthy subjects a 7-day course of treatment with cimetidine (800 mg day-1), ranitidine (300 mg day-1) or famotidine (40 mg day-1), did not modify the pharmacokinetics of ethanol given as a post-prandial 0.3 g kg-1 dose. We conclude that gastric mucosal concentrations of histamine H2-receptor blockers achieved after oral dosing are probably too low to cause significant inhibition of gastric ADH in vivo.     

Lack of effect of histamine H2-receptor antagonists on indocyanine green disposition measured by two methods

Eleven healthy male volunteers were treated according to a randomized, crossover design with ranitidine (300 mg/day), cimetidine (1200 mg/day), or nothing for 48 hours. Ninety minutes after the 48-hour dose, each volunteer was given 0.5 mg/kg indocyanine green by iv bolus. Indocyanine green plasma concentrations were measured by the traditional spectrophotometric method at 800 nm and by HPLC simultaneously monitored at 214 and 656 nm. Neither histamine H2-receptor antagonist altered the disposition of indocyanine green. The mean (+/- S.D.) plasma clearance by the spectrophotometric method was 7.48 +/- 2.07 (control), 7.15 +/- 3.07 (ranitidine), and 6.88 +/- 1.35 ml/min/kg (cimetidine). The power to detect a 20 per cent change is 0.87. The spectrophotometric method generally produced a biexponential plasma concentration decay, whereas the HPLC method resulted in a monoexponential decay. Analysis of the 5- to 15-minute data by the conventional technique showed that although indocyanine green total plasma clearance was not significantly different for the two methods (P greater than 0.10), the volume of distribution was significantly greater (P less than 0.001) and the elimination rate constant was significantly smaller (P less than 0.001) for the spectrophotometric than the HPLC method. Although neither ranitidine nor cimetidine chronic administration alters indocyanine green disposition by either method, the absolute values of the pharmacokinetic parameters are dependent upon the analytical technique employed.     

Effect of H2-receptor antagonists on the pharmacokinetics of 5-fluorouracil in the rat and monkey.

The effect of short term (7 days) and long term (28 days) pretreatment with the imidazole H2-receptor antagonist, cimetidine (CMT), on the pharmacokinetics of 5-fluorouracil (5-FUra) has been studied in the rat and cynomolgus monkey. Short-term pretreatment of rats with CMT significantly increased t1/2.z by 29 per cent and AUC by 40 per cent: total body clearance was decreased by 30 per cent. Long-term pretreatment exaggerated these effects. By contrast, short- and long-term pretreatment with the furan H2-receptor antagonist, ranitidine, caused no significant effect on 5-FUra kinetics. In the monkey, 7 days pretreatment with CMT increased t1/2.z by 32 per cent leaving other 5-FUra kinetic parameters unchanged; 28 days pretreatment increased both t1/2.z by 41 per cent and AUC by 100 per cent with a decrease in total body clearance of 5-FUra of 48 per cent. CMT, but not RNT, inhibited cytosolic dihydropyrimidine dehydrogenase (DPD), the enzyme responsible for 5-FUra catabolism. It is proposed that the observed effects of CMT on 5-FUra kinetics are the result of inhibition of DPD. This interaction has the potential for increasing systemic drug toxicity and it is therefore advisable that where H2-receptor blockade is administered concurrently with 5-FUra that a non-imidazole based H2-receptor antagonist such as RNT should be substituted for CMT.     

Clinical pharmacokinetics of H1-receptor antagonists (the antihistamines)

This article reviews clinical pharmacokinetic data on the H1-receptor antagonists, commonly referred to as the antihistamines. Despite their widespread use over an extended period, relatively little pharmacokinetic data are available for many of these drugs. A number of H1-receptor antagonists have been assayed mainly using radioimmunoassay methods. These have also generally measured metabolites to greater or lesser extents. Thus, the interpretation of such data is complex. After oral administration of H1-receptor antagonists as syrup or tablet formulations, peak plasma concentrations are usually observed after 2 to 3 hours. Bioavailability has not been extensively studied, but is about 0.34 for chlorpheniramine, 0.40 to 0.60 for diphenhydramine, and about 0.25 for promethazine. Most of these drugs are metabolised in the liver, this being very extensive in some instances (e.g. cyproheptadine and terfenadine). Total body clearance in adults is generally in the range of 5 to 12 ml/min/kg (for astemizole, brompheniramine, chlorpheniramine, diphenhydramine, hydroxyzine, promethazine and triprolidine), while their elimination half-lives range from about 3 hours to about 18 days [cinnarizine about 3 hours; diphenhydramine about 4 hours; promethazine 10 to 14 hours; chlorpheniramine 14 to 25 hours; hydroxyzine about 20 hours; brompheniramine about 25 hours; astemizole and its active metabolites about 7 to 20 days (after long term administration); flunarizine about 18 to 20 days]. They also have relatively large apparent volumes of distribution in excess of 4 L/kg. In children, the elimination half-lives of chlorpheniramine and hydroxyzine are shorter than in adults. In patients with alcohol-related liver disease, the elimination half-life of diphenhydramine was increased from 9 to 15 hours, while in patients with chronic renal disease that of chlorpheniramine was very greatly prolonged. Little, if any, published information is available on the pharmacokinetics of these drugs in neonates, pregnancy or during lactation. The relatively long half-lives of a number of the older H1-receptor antagonists such as brompheniramine, chlorpheniramine and hydroxyzine suggest that they can be administered to adults once daily.     

Potential histamine H2-receptor antagonists. 2. N-alpha-Guanylhistamine.

The agonist molecule, histamine, has been used as a starting point for the design of potential H2-receptor antagonists. Converting the side-chain amino group into a guanidine yielded the first histamine H2-receptor antagonist, Nalpha-guanylhistamine. Antagonism of H2 receptors was demonstrated by the inhibition of histamine-stimulated gastric acid secretion in the rat at high dose levels (approximate ID50 800 MUmol/kg, iv) and by the inhibition of histamine-stimulated tachycardia of guinea-pig right atrium (pA2 equals 3.9). Guanylhistamine behaves as a partial agonist at histamine H2 receptors.     

Cardiovascular effects of H2-receptor antagonists

The type II histamine receptor antagonists, cimetidine and ranitidine, widely used in treatment of peptic ulcer disease have been reported to cause bradycardia. To evaluate the cardiovascular effects of H2 antagonists nineteen healthy volunteers were entered into a double-blind crossover comparison of cimetidine 300 mg qid, ranitidine 150 mg bid, and placebo. Subjects ingested study medicine for 7 days prior to being tested by the Bruce Exercise Test. Heart rate, blood pressure, oxygen consumption, expiratory volume, and fractional expiration of CO2 and O2 were measured at rest, exercise and recovery. A plasma sample for determination of cimetidine and ranitidine levels were obtained prior to the exercise period. Multivariate analysis and paired t test revealed no significant differences for the cardiovascular or pulmonary variables. However, in 5 subjects, the heart rate at 25% maximum VO2 was depressed 8% (P less than or equal to 0.03). This effect in a small percentage of the population suggests that further studies are needed to determine if subpopulations are affected.     

Biliary excretion of H2-receptor antagonists

Summary The biliary excretion of ranitidine and famotidine has been studied using percutaneous biliary drainage in patients with complete extrahepatic biliary obstruction due to pancreatic carcinoma. Following 50 mg ranitidine i. v. 0.7 to 2.6% of the dose was recovered in bile collected over 24 h. At steady state (300 mg ranitidine/d po) a similar amount (0.3 to 1.0% of daily dose) was excreted by this route (n = 3). Following single i.v. (20 mg) and oral (40 mg) doses of famotidine (n = 2), even lower percentages (0.1% and 0.4%, respectively) were recovered in the 24 h bile. This negligible biliary excretion cannot account for the so-called second peak phenomenon observed in some individuals following a single dose of an H2-receptor antagonist.     

Potential histamine H2-receptor antagonists. 4. Benzylhistamines

As part of our studies aimed at designing histamine H2-receptor antagonists, the effect on histaminergic activity of introducing benzyl substituents at various positions in the histamine molecule is described. New synthetic methods are reported for the novel 4-benzyl-, beta-benzyl- and 4,N tau-dibenylhistamines and the reported 2-benzylhistamine. The novel N tau-benzylhistamine was synthesized by the versatile route reported by us for the synthesis of N tau-methylhistamine. These benzylhistamines, together with the reported N alpha- and N pi-benzylhistamines, were tested for agonist and antagonist activity at both H1 and H2 receptors. The results obtained indicate that introduction of a benzyl group into the histamine molecule causes a marked reduction in H1- or H2-agonist activity, and none of the compounds showed consistent antagonist activity. Evidently, the sterically demanding benzyl substituent is not easily accommodated in the agonist binding mode and is unable to locate a lipophilic receptor region for potential hydrophobic binding.     

Influence of the H2-receptor antagonists cimetidine and ranitidine on the pharmacokinetics of nimodipine in healthy volunteers

Summary A possible interaction between the calcium antagonist nimodipine and the H₂-receptor antagonists cimetidine and ranitidine has been investigated in two separate studies in healthy subjects.In eight young volunteers the concomitant administration of nimodipine 30 mg t.i.d. and cimetidine 1000 mg/d for 7 days led to a significant increase of the relative bioavailability of nimodipine. The changes in the pharmacokinetic parameters were not accompanied by discernible haemodynamic effects or any change in the tolerability of nimodipine.There was no evidence of any significant change in the steady-state pharmacokinetics of nimodipine during five days of combined treatment with 30 mg t.i.d. nimodipine and ranitidine 300 mg/d given as single morning dose to twelve healthy, elderly subjects. Analysis of haemodynamics, clinical chemistry and tolerance also did not reveal any difference between the two treatment periods.Presented in part at the IVth World Conference on Clinical Pharmacology and Therapeutics, Mannheim-Heidelberg, 23–28 July, 1989     

Potential histamine H2-receptor antagonists. 3. Methylhistamines.

Syntheses are described for all the mono- and some di- and trimethylhistamines. New methods are given for the known Npi, Ntau-, Nalpha-, 2-, and 4-methylhistamines and for the novel compounds, beta-methyl-, 4,Nalpha-dimethyl-, and 4,Nalpha,Nalpha-trimethylhistamines. Agonist activities are reported for stimulation of histamine H1 (guinea-pig ileum) and H2 (rat gastric acid secretion) receptors. H2-Receptor agonist activities indicate that a methyl group is more readily accommodated at the 4 and Nalpha positions than elsewhere in the histamine molecule and that receptor binding is substantially retained with a methyl substituent in these positions. Thus, for the design of potential antagonists, two sites are identified as being worthwhile exploring for the introduction of lipophilic substituents.     

Cardiac effects of the new H2-receptor antagonists

A series of new H2-receptor antagonists were tested for their effects on different isolated heart preparations. In the guinea-pig atria and papillary muscle the inhibitory effect on histamine H2-receptors was evaluated. In the perfused rabbit heart and in strips of human atria the effect of the H2-antagonists on the spontaneous or electrically-stimulated contractions was evaluated. In the first two preparations some main quantitative differences were pointed out, tiotidine and compound SKF 93479 being the most potent antagonists, cimetidine, metiamide and ranitidine the less effective. In the rabbit heart and in human atria results were quite different: cimetidine and ranitidine were virtually ineffective up to the maximum concentration tested (3 x 10(-3) M), oxmetidine and compound SKF 93479 had a negative inotropic and chronotropic effect starting from concentrations of 3 x 10(-6)-10(-5) M. On the basis of the behaviour of other compounds endowed with negative cardiac effects (propranolol, anaesthetic-like compounds, verapamil) and of that of compounds capable of counteracting the effect of oxmetidine (increased concentration of calcium ions and isoproterenol) it was hypothesized that oxmetidine may interfere in the transport of calcium ions. Our data emphasize the importance of the different structure of the H2-antagonists in determining non-specific effects absolutely independent of the primary action that is the H2-receptor blockade.     

The effects of H2-receptor antagonists on anaphylaxis in the guinea-pig.

Histamine has been shown to inhibit a variety of immune responses including the antigen-induced, IgE mediated, release of histamine from sensitized human leucocytes and from sensitized monkey and dog mast cells. The inhibitory action of histamine appears to be mediated by action at a histamine H2-receptor. In in vitro experiments the H2-receptor antagonist metiamide has been shown to block this histamine effect and it has been suggested that H2-receptor antagonists could intensify immediate hypersensitivity reactions in vivo. The effects of the H2-receptor antagonist metiamide and cimetidine have been studied in in vitro and in vivo models of anaphylaxis in the guinea-pig. The amount of extracellular histamine found after antigen challenge is greater when an H2-receptor antagonist is present during the incubation of mast cells with antigen. Bronchoconstriction induced by antigen in sensitized guinea-pig is exacerbated only by high doses of cimetidine. Possible explanations for the mechanism of action involved are discussed.     

Role of H2-receptor antagonists in the treatment of duodenitis.

Non-erosive duodenitis is an ulcer-independent disorder, the pathogenesis of which is still unclear but apparently unrelated to gastric hyperacidity. However, antisecretory agents such as H2-blockers can be effective not only in relieving dyspeptic symptoms but also in promoting endoscopic healing or improvement. In this respect conflicting data are reported with cimetidine while promising, although preliminary, results were obtained with ranitidine and with nizatidine. Nizatidine seems especially effective when administered at a dose of 150 mg b.i.d., a regimen providing moderate, but continuous acid inhibition throughout a 24 hour period.     

Effects of H2-receptor antagonists on the central nervous system

Histamine functions as a neurotransmitter in the central nervous system (CNS), and H₂-receptor activation can modulate the activity of the CNS. H₂-receptor antagonists are known to penetrate the blood-brain barrier and to cause neuropsychiatric effects. It appears that interactions with CNS H₂-receptors may account for many of these effects, although receptor interactions unique to certain H₂-antagonists may also play a role.     

Effect of H2-receptor antagonists on acetaminophen-induced hepatic injury

The effects of H2-antagonists on acetaminophen-induced hepatic injury were examined. Rats were administered acetaminophen at the dose of 800 mg/kg body, 60 hr after injection of 3-methylcholanthrene. As an H2-antagonist, cimetidine (200 mg/kg), ranitidine (50 mg or 100 mg/kg), or famotidine (20 mg or 40 mg/kg) was administered before and after acetaminophen injection. The group administered only acetaminophen had been severely damaged as evaluated by changes in serum transaminase, P-450 content, aminopyrine demethylation, glutathione content and histological study, but administration of 200 mg cimetidine together with acetaminophen significantly reduced the hepatic injury to nearly the control level. Ranitidine had no protective effect against hepatic injury at the dose of 50 mg, which appears to have the same antacid effect as 200 mg cimetidine, whereas it had a slight but significant protective effect as evaluated by the transaminase level, glutathione content and histological study at the dose of 100 mg. Famotidine had no effect against acetaminophen induced hepatic injury. Because famotidine had no effect, the protection by H2-antagonist against acetaminophen-induced hepatic injury cannot be explained by the decrease in hepatic blood flow alone. Therefore, inhibition of P-450 activity seems to be more important for reducing the generation of the reactive metabolites of acetaminophen than hepatic blood flow decrease.     

Substituent effect on the stereochemistry of H2-receptor antagonists of the phenylformamidine series. A conformation-dependent mode of interaction with the H2 receptor.

The influence of alkyl substitution on the stereoisomerism of the formamidine cation (E,E vs E,Z) of several N-substituted (imidazolylphenyl)formamidines (1-10) was investigated. As (imidazolylphenyl)formamidines having alkyl substituents of more than three carbon atoms bind to H2-receptor preparations in a pseudoirreversible mode causing unsurmountable antagonism, the four isomeric butylformamidines (5-7 and 9) having comparable lipophilic character but different E,E/E,Z composition were investigated in H2-receptor assays to determine quantitatively any difference in their pseudoirreversible inhibitory pattern. It was found that the geometry of the formamidine cation is affected by the steric bulk of the substituent on the formamidine nitrogen. A relationship between the percentage of the E,E conformation of the formamidine cation and degree of pseudoirreversible antagonism was also found. The present studies support the hypothesis that bidentate hydrogen bonding plays an important role in the interaction of (imidazolylphenyl)formamidines with the H2 receptor.     

Effects of H2-receptor antagonists on ethanol metabolism in Japanese volunteers.

The effects of H2-receptor antagonists (cimetidine, ranitidine, and famotidine) on ethanol metabolism were investigated. Neither in aldehyde dehydrogenase (ALDH)-1 deficient subjects nor in those with normal ALDH-1, did the three H2-receptor antagonists and placebo differ in their effects on the pharmacokinetic parameters of ethanol (i.e. peak time (tmax), metabolic rate (k0), peak serum concentration (Cmax), volume of distribution (V) and area under the concentration-time curve (AUC). The AUC of acetaldehyde was slightly but significantly (P less than 0.05) larger only after treatment with cimetidine. Cmax and tmax of acetaldehyde were unchanged.