Pharmacokinetics of verapamil and norverapamil in patients with hypertension: a comparison of oral conventional and sustained release formulations

A double blind, double dummy, randomized cross-over pharmacokinetic study comparing verapamil 120 mg, conventional tablets administered twice daily and verapamil 240 mg sustained release tablets once daily was performed in 12 patients with essential hypertension. After frequent blood sampling, analyses of verapamil and norverapamil were made with high pressure liquid chromatography. The absorption rate of the sustained release formulation was significantly slower than for the conventional formulation. Also the mean residence time was significantly longer for the sustained release tablet. It can be concluded that verapamil sustained release tablets meet with the following requirements for these formulations: (1) a slower absorption with an acceptable bioavailability relative to conventional tablets (89%); (2) no initial high peak concentration; (3) little fluctuation in the plasma concentration compared to the conventional formulation; (4) no differences in the elimination half lives for the two formulations; (5) maintenance of a therapeutic plasma level for a longer period of time than for the conventional formulation; (6) no increase in unwanted side effects.     

Pharmacokinetics of sustained-release verapamil after a single administration and at steady state

Pharmacokinetics of conventional 80 mg tablets and two types of sustained-release (SR) tablets containing 120 and 200 mg of verapamil were compared cross-over in 12 healthy volunteers. Serum concentrations of verapamil and norverapamil were analyzed both after a single oral dose and at steady state after t.i.d. administration of conventional tablets and b.i.d. administration of SR tablets. After 120 mg SR tablets serum concentrations of verapamil usually remained below 100 ng/ml for 5 days. This inadequate bioavailability was caused by very slow absorption. The relative bioavailability of verapamil in 200 mg SR tablets was 93-96% as compared to the conventional tablets. After 200 mg X 2 and 80 mg X 3, the peak serum levels were about 300 and 190 ng/ml, respectively and the trough levels 123-153 and 52-56 ng/ml, respectively. The verapamil/norverapamil ratio varied from 0.69 to 0.84 after a single dose and from 0.8 to 0.93 at steady-state. By the 4th days of treatment, the accumulation ratios ranged between 1.75-2.07 and 1.30-1.75 for verapamil and norverapamil, respectively. For each preparation studied, the apparent Cltot of verapamil was significantly reduced at steady-state. These results show that 200 mg SR verapamil tablets fulfill the basic requirements of retard preparations allowing for twice or even once daily administration.     

Effect of slow release nifedipine tablets in patients with essential hypertension.

The antihypertensive effect of slow release nifedipine (CAS 21829-25-4) tablets (20 mg, Adalat) administered once or twice daily was studied in patients with essential hypertension of WHO stage I or II. Ambulatory blood pressure was monitored by a finger volume oscillometric device every 5 min for 24 h before and during the treatment with nifedipine. Whether administered once or twice daily, nifedipine tablets dit not change the pattern of circadian blood pressure variation; i.e. diurnal rise and nocturnal fall. Twice daily administration induced a significant downward shift in the blood pressure pattern. In other words, further hypotensive effect was observed during the night when the blood pressure was already low. On the other hand, administration once daily in the morning lowered daytime blood pressure without affecting blood pressure during the night. The duration of action of nifedipine tablets administered once daily was 12 h or more. In the acute experiment using 20 mg tablets of nifedipine, plasma concentration of nifedipine was well correlated with the percentage change in mean blood pressure. The minimal effective plasma concentration of nifedipine was estimated to be 13.4 ng/ml. However, in chronic treatment, nifedipine lowered blood pressure at the plasma concentration of 10 ng/ml. The results indicate that nifedipine tablets administered once daily provide an effective antihypertensive regimen for controlling daytime hypertension with minimal antihypertensive effect during the night.     

Once daily administration of sustained release propranolol capsules in the treatment of angina pectoris

Summary The effect of once daily administration of sustained release capsules of propranolol 160 mg was compared with treatment with standard 40 mg tablets four times daily, in eight patients with stable angina pectoris, in a four week, double blind crossover, random treatment-order trial. Clinical evaluation and submaximal bicycle ergometry were performed before propranolol therapy and on the last day of each treatment period. Serum propranolol concentration over a 24 hour period on those two days ranged from 34.4 to 65.5 ng/ml for the tablets, and 27.7–76.0 ng/ml for the capsules. The peak increase in heart rate on exercise fell from 59 beats per minute to 43 and 41 bpm following the tablets and capsules, respectively (p<0.05). The degree of ST segment depression decreased from 1.94 mm to 0.94 mm and 0.63 mm, respectively (p<0.05). Serum propranolol concentrations were significantly correlated with the reduction in peak heart rate (r=0.58, p<0.05), and in heart rate-pressure product (r=0.83, p<0.01). Clinical attacks and nitroglycerin requirements were equally reduced by both formulations. Sustained release capsules of propranolol 160 mg given once daily were as effective as standard 40 mg tablets given four times daily in the treatment of stable angina pectoris in patients requiring this dose range.     

Pharmacokinetics of verapamil and its metabolite norverapamil from a buccal drug formulation

Pharmacokinetics of verapamil and its metabolite norverapamil, from buccal drug formulation administered in a dose 20 mg in relation to conventional tablets of verapamil 40 mg, used in medical practice, was determined. Buccal formulation has previously been designed as an alternative form of dosing verapamil. Bioavailability was determined by a crossover method in 12 healthy volunteers. Drug concentration in plasma was determined by means of HPLC with a fluorescence detector. For buccal formulation the average values of C(max) and AUC(0-24 h) for verapamil were much higher than for the reference Staveran tablets and amounted to 51.28 and 320.23 ng/ml h, respectively. However, for norverapamil the corresponding values for buccal formulation were much lower than for a conventional tablet. It has been demonstrated that the proposed buccal verapamil dosing ensures different metabolism of the drug as compared to tablets. Better parameters of bioavailability of verapamil from buccal formulation of twice a smaller dose than that in the tablet, prove that this new drug might be form more effective clinically than the conventional one.     

Altered Pharmacokinetics and Metabolism of Valproate after Replacement of Conventional Valproate with the Slow‐Release Formulation in Epileptic Patients

Abstract: Altered metabolism of valproate has been suggested as the mechanism of teratogenicity and hepatotoxicity of valproate. This study aimed at examining whether pharmacokinetics of a slow‐release formulation of valproate affects valproate metabolism. Thirty‐one epileptic patients were treated with fixed‐doses of conventional valproate for at least 2 months. Thereafter, the drug was replaced with the same doses of slow‐release formulation of valproate for 2 months. Blood samplings for determination of valproate and its metabolites by gas chromatography‐mass spectrometry were performed at three time‐points (just before morning dose and at 1 and 5 hr after morning dose) during both treatment phases. There was a significant difference (P<0.005) in the mean serum concentration (±S.D.) of valproate after 1 hr between conventional valproate (63.1±27.9 μg/ml) and slow‐release formulation of valproate (45.7±19.5 μg/ml). Mean serum concentrations (±S.D.) of 4‐en and hydroxy metabolites after 5 hr were significantly reduced after replacement with slow‐release formulation of valproate (4‐en: 29.5±14.0→23.0±15.3 ng/ml, 3‐OH: 488.5±234.0→419.6±171.1 ng/ml, 4‐OH: 404.3±124.7→342.8±147.6 ng/ml, 5‐OH: 102.8±54.4→81.0±43.6 ng/ml). The present study suggests that smaller diurnal fluctuations in valproate concentrations during treatment with slow‐release formulation of valproate result in decreased formations of minor metabolites including 4‐en, the most toxic metabolite.     

Pharmacokinetic characteristics of a new multiple unit sustained release formulation of sodium valproate

AIM: Two bioavailability studies were conducted in healthy male volunteers to determine the absorption characteristics of a new dosage form of sodium valproate consisting of sustained release pellets in a hard gelatine capsule. SUBJECTS, MATERIAL AND METHODS: To obtain first data on the in vivo behavior of the new multiple unit formulation a single dose pilot study in comparison with an oral solution was performed in 6 volunteers. Following the pilot study the pharmacokinetics were investigated versus a conventional enteric-coated tablet after multiple dosing in 18 volunteers. The volunteers were administered either a single or multiple dose of 300 mg sodium valproate. In both studies a wash-out period of at least 1 week elapsed between the periods. Valproic acid was determined from serum by gas chromatography at intervals suitable for obtaining concentration time curves for both regimens. RESULTS: The results of the pilot study showed that the valproate concentration in serum following administration of the new sustained release capsule increased smoothly and a longer lasting plateau was observed as compared with the solution. The average maximum serum valproate concentration of 12.5 microg/ml (sustained release capsule) and 24.3 microg/ml (solution) appeared at 9.3 h and 0.58 h after dosing. The extent of valproate absorption as reflected in the AUC data for each formulation was equivalent for the new sustained release capsule and reference formulation (AUC0-infinity: 369 +/- 88.9 and 339 +/- 76.2 microg/ml x h). Data obtained after multiple dose administration provided an indication of the consistency of valproate absorption from each dosage form. The time concentration profiles following twice daily administration of 300 mg sodium valproate in the multiple dose study showed that the extent parameters for absorption of valproate (AUC(8tau9tau) = 842 +/- 166 microg/ml x h) are equivalent with the enteric-coated preparation (AUC(8tau9tau) = 823 +/- 139 microg/ml x h). However, the fluctuation of the new sustained release formulation (PTF(8tau9tau) = 0.33 +/- 0.09) is about only one third of the fluctuation observed with the enteric-coated formulation (PTF(8tau9tau) = 0.88 +/- 0.22) when administered twice daily. CONCLUSION: These data indicate that the new sustained release capsule possesses desirable absorption characteristics in a form that allows twice daily or even once daily dosing and therefore improves patient compliance.     

Multiple-dose pharmacokinetics of naproxen from a controlled-release tablet in healthy volunteers

The pharmacokinetics of a new controlled-release tablet of naproxen (750 mg) given once daily has been studied in healthy volunteers, in comparison with two doses of the conventional naproxen tablets (375 and 500 mg) administered twice daily. Steady-state plasma concentrations of naproxen were achieved after two days of repeated administration of both the controlled-release and the conventional tablets. On day seven, peak concentration, cowest concentration and the steady-state average plasma concentration values of the controlled-release tablet were significantly higher than those of 375 mg conventional tablet and comparable to those of 500 mg conventional tablet. Areas under the plasma concentration-time curve indicated an equal extent of absorption between the new and the conventional formulation. Overall the controlled-release tablet administered once daily mimicked a twice daily regimen so suggesting that the new formulation could be suitable for once daily dosing.     

Fraction of theophylline in sustained-release formulation which is absorbed from the large bowel

Summary In a cross-over study of six healthy male volunteers, 500 mg theophylline was administered either as plain tablets or in a sustained release preparation. On each occasion 2 g of non-enteric coated sulphasalazine was administered simultaneously as the time of appearance of sulphapyridine, the product of hydrolysis, in the blood provides an approximation of the oral — caecal transit time. The mean fraction absorbed — time profile was calculated from serial serum concentration measurements of theophylline by a modification of the Wagner-Nelson equation. The mean cumulative fraction of the dose absorbed following administration of the plain tablets was maximal at 3 h i.e. approximately 3 h ahead of the mean oral-caecal transit time, which was 5.9 h. Thus complete absorption occurred in the small intestine.With the sustained — release formulation, approximately only half of the dose was absorbed at the time the medication reached the large bowel i.e. at about 5.4 h. Absorption continued and at least 38% of the administered dose was additionally absorbed over the next 25 h.A reliable lengthened dosage interval is therefore possible with this particular sustained — release formulation.     

Pharmacokinetics of verapamil in patients with hypertension

Summary Twelve hypertensive patients (WHO Stage I-II) were given oral verapamil (Isoptin) b.d. or t.d.s. as long-term treatment. The pharmacokinetics of verapamil and norverapamil were studied both after single and b.d. and t.d.s. doses of verapamil 240, 360 or 480 mg daily adjusted according to the blood pressure response. The apparent oral clearance of verapamil was decreased after both the twice and thrice daily dosage regimens (1.38 and 1.841/min, respectively) as compared to the single dose (4.39 l/min). The plasma half-life of verapamil was increased from 3.34 h (single dose) to 4.65 h (b.i.d.). Decreased elimination of norverapamil was also found after multiple doses of verapamil, as shown by an increase in the adjusted AUC of norverapamil (adjusted to a verapamil dose of 80 mg), namely from 574.9 h·ng·ml^–1 (single dose) to 1172 h·ng·ml^–1 (b.d.) and to 841 h·ng·ml^–1 (t.d.s.). The plasma half-life of norverapamil increase from 5.68 h to 7.34 h during twice daily dosing. During thrice daily verapamil, no increase in plasma half-life was found either for verapamil or norverapamil, probably due to the relatively short sampling time (6 h). The plasma concentration of verapamil and the reduction in supine systolic and diastolic blood pressure were correlated. The mean decrease in supine systolic blood pressure was 5.8 mm Hg per 100 ng verapamil/ml plasma, and for diastolic pressure 2.9 mm Hg per 100 ng verapamil/ml plasma. The mean steadystate plasma concentrations of verapamil were similar after twice and thrice daily dosing regimens, which agrees with the clinical observation that blood pressure control in hypertensive patients is as good after verapamil b.d. and t.d.s.     

Sustained-release and instant-release verapamil in treatment of angina pectoris

Summary The efficacy of a sustained-release preparation of verapamil (verapamil-IR) has been compared with that of a conventional instant-release formulation (verapamil-IR) in 10 patients with stable angina pectoris treated for 3 weeks with both preparations.The diurnal serum concentrations of verapamil and norverapamil did not differ significantly during treatment with verapamil-IR 120 mg t.i.d. and verapamil-SR 360 mg once daily, but verapamil-SR 240 mg produced significantly lower serum concentrations. The differences did not affect the exercise capacity or the occurrence of ST-segment depression during maximal exercise.Verapamil-SR was well tolerated. A multiple instant-release dosage regime can now be replaced by once daily administration of the sustained-release preparation.     

Lithium treatment regimen and renal water handling: The significance of dosage pattern and tablet type examined through comparison of results from two clinics with different treatment regimens

For many years two Danish psychiatric hospitals have used different lithium treatment regimens. In one, slow-release tablets were given in two daily doses and, in the other, conventional tablets were given in a single daily dose. In both hospitals many patients developed polyuria. Multiple regression analyses with sex, age, treatment duration, serum lithium concentration, and treatment regimen as predictor variables showed that the two treatment regimens did not affect the glomerular filtration rate or the proximal reabsorption differently, but that distal water reabsorption was significantly less affected and polyuria less pronounced in the patients given conventional tablets once daily than in those given slow-release tablets twice daily. The authors are divided among themselves as regards the implications of these findings.     

Pharmacokinetic and pharmacodynamic properties of a new controlled-release formulation of metoprolol: A comparison with conventional tablets

The pharmacokinetic and pharmacodynamic properties of a new multiple-unit, controlled-release (CR) formulation of metoprolol¹ (metoprolol succinate, 95 mg once daily), which has almost constant (zero-order) release properties over most of a 24-h dose interval, have been compared with those of conventional metoprolol tablets (metoprolol tartrate, 100 mg once daily and 50 mg twice daily), in 12 healthy male volunteers.The steady-state plasma concentrations of metoprolol after five days of treatment varied less throughout the day with the CR than with the conventional formulation. This was associated with a considerably lower peak plasma concentration and the achievement of a significantly higher plasma concentration at the end of the dose interval.     

Pharmacokinetics of verapamil and norverapamil from controlled release floating pellets in humans.

Pharmacokinetics of verapamil (V) in a dose of 40 mg and its metabolite norverapamil (N) from the new oral drug formulation in a form of capsule filled with floating pellets was determined. Conventional 40-mg tablets used in a medical practice served as a reference. Bioavailability studies were carried out in 12 healthy volunteers including six men and six women. In an in vitro test the pellets floated on the surface of the extraction fluid for 6 h. Mean value of maximum plasma concentration (C(max)) of V for floating pellets was 28.27 ng ml(-1) and t(max) 3.75 h. The value of the area under the concentrations versus time, AUC(0-infinity) was calculated as 364.65 ng ml(-1) h, biological half-lives of the absorption and elimination (t(0.5el)) phase were 0.5 h and 10.68 h, respectively. For the reference conventional tablets those values were 33.07 ng ml(-1), 1.21 h, 224.22 ng ml(-1) h, 0.36 h and 6.17 h, respectively. The average concentration of N in plasma was similar to that of V.     

Clinical pharmacokinetics of verapamil in patients with atrial fibrillation

Summary The pharmacokinetic parameters and oral bioavailability of the antiarrhythmic drug verapamil were determined in six patients with atrial fibrillation. Plasma samples were taken following i.v. injection of verapamil 10 mg (Isoptin^® 2 ml), and oral verapamil 80 mg (Isoptin^® 2 tablets of 40 mg). Verapamil and its N-demethylated metabolite, norverapamil, were analyzed to 1 ng/ml plasma by gas chromatography-mass spectrometry using deuterated standards. Following intravenous injection, the disposition of verapamil followed a biexponential pattern with a fast distribution phase and a slower elimination phase (t_1/2=5.79 h), corresponding to a plasma clearance of 0.26 1/kg/h. After oral administration, only an elimination phase was evident, with the same elimination rate (t_1/2=5.53 h). The oral bioavailability was 10.5%±7.5%. The norverapamil formed after i.v. and oral administration of verapamil had plasma half-lives of 5.86 h and 6.77 h, respectively. The elimination of verapamil in patients with atrial fibrillation was decreased compared to that in healthy young volunteers and the oral bioavailability was lower. Very good correlation between the percentage reduction in heart rate and the log plasma concentration of verapamil was found in every patient during the elimination phase, irrespective of the route of administration. There was also a high correlation when the plasma concentration — effect data from all the patients were pooled (r=0.59,n=71;p<0.0005).     

Beta-blocking effect and serum levels of alprenolol in man after administration of ordinary and sustained release tablets

Summary The effect of alprenolol administered as ordinary and as sustained release tablets was compared by studies on the inhibition of the haemodynamic response to physical work. Serum levels of alprenolol were also determined. Two types of double-blind cross-over studies were performed in healthy volunteers. In one the effects of ordinary tablets, sustained release tablets and a placebo were followed for 12 h. In two other studies each preparation was given for five days. The sustained release tablets were given b.i.d., and were compared with ordinary tablets administered q.i.d., or with a placebo. A dose of 200 mg alprenolol in sustained release tablets had almost the same initial peak effect as 100 mg in ordinary tablets. The duration of the effect was longer after the sustained release tablets, and 200 mg b.i.d. gave approximately the same degree of beta-blockade during the day as 100 mg in ordinary tablets given q.i.d. The results indicated that both dosage regimens had an effect for 24 h, and that more constantive effect levels were obtained by the use of sustained release tablets. No accumulation was found in the five day study, neither in terms of the pharmacological effects nor of serum levels of alprenolol. The concentration of alprenolol in serum rarely exceeded 10 ng per ml, and approximately the same steady state level was obtained after sustained release tablets as after ordinary tablets.     

Evaluation of a sex-based difference in the pharmacokinetics of digoxin

STUDY OBJECTIVE: To determine whether a sex-based difference in digoxin pharmacokinetics exists in patients receiving long-term digoxin therapy for chronic heart failure or atrial fibrillation. DESIGN: Single-center, retrospective review of medical records. SETTING: University-based teaching hospital and outpatient clinic. PATIENTS: Sixty-seven adults (32 men, 35 women) with chronic heart failure or atrial fibrillation who were receiving digoxin therapy. MEASUREMENTS AND MAIN RESULTS: Serum digoxin concentrations and daily digoxin doses were obtained from patients' medical records. Daily doses were adjusted for patients' actual and ideal body weight and body mass index (BMI). The ratio between the serum digoxin concentration and each of the adjusted daily doses of digoxin was compared between men and women. The mean +/- SD serum digoxin concentration was 0.85 +/- 0.51 ng/ml for men compared with 1.02 +/- 0.51 ng/ml for women. Mean +/- SD unadjusted doses of digoxin were 0.180 +/- 0.063 and 0.164 +/- 0.059 mg/day for men and women, respectively; the difference was not statistically significant. Ratios of serum digoxin concentration to daily digoxin doses did not differ by sex when doses were estimated with actual or ideal weight. Only the ratio of the digoxin concentration to the BMI-adjusted dose was significantly different between men and women (0.14 +/- 0.09 and 0.19 +/- 0.11, respectively, p<0.05). CONCLUSION: Sex-based differences in digoxin pharmacokinetics were absent when actual or ideal body weight was used. However, the ratio of serum digoxin concentration to daily digoxin dose adjusted for BMI differed by sex. Because digoxin is distributed to lean body mass, use of the BMI could have overadjusted body weight, leading to inaccurate pharmacokinetic assumptions and calculations. The pharmacokinetics of digoxin do not appear to differ by sex.     

Multiple dose comparison of a whole 240 mg verapamil sustained-release tablet with two half tablets

Twelve healthy male volunteers were studied in a balanced crossover comparison of an intact 240 mg verapamil sustained-release tablet (Securon SR, Isoptin Forte Retard) given once daily for 7 days, and the same dose given as two half tablets. One subject was withdrawn because of asymptomatic second degree heart block on day 3 of verapamil treatment. The mean Cmax after dosing with whole tablets, 143 (95 per cent confidence limits 91.6-223) ng ml-1 was lower than after dosing with half tablets, 160 (107-241) ng ml-1, but this was not significant (p = 0.49). The mean steady-state Cmin values after whole and half tablets were also similar: 22.2 (12.6-39.4) ng ml-1 and 22.0 (16.2-29.9) ng ml-1, respectively (p = 0.96). The mean (+/- S.D.) tmax, AUC0-24 and t 1/2 were not significantly different: whole tablet 3.5 +/- 1.2 h, 1733 +/- 1125 ng.h ml-1 and 10.5 +/- 3.4 h, respectively, and half tablets 3.6 +/- 1.0 h, 1780 +/- 1057 ng.h ml-1 and 9.6 +/- 2.3 h, respectively. The findings for plasma norverapamil were generally similar to those for the parent drug. This investigation indicates that the formulation is sufficiently robust to retain its sustained-release properties when the tablet is halved.     

Clinical study on digoxin tablets with high bioavailability (author's transl)

The relationship between different maintenance doses and the steady-state digoxin blood concentration was studied in 160 patients with heart failure. All patients received digoxin tablets of the same brand (Digacin). The bioavailability of this brand is 82% compared with an i.v. standard. During the treatment with daily doses of 0.2 mg and 0.3 mg average serum digoxin levels of 1.09 +/- 0.45 ng/ml and 1.33 +/- 0.53 ng/ml were measured in patients with normal renal function. The daily dose of 0.4 mg digoxin was in correlation to an average serum level of 1.75 +/- 0.81 ng/ml. 81% and 86% of all patients with normal renal function taking 0.2 or 0.3 mg digoxin every day were found to have levels in the range of 0.7 to 2.0 ng/ml. The influence of sex, age, height, body weight, maintenance dose, serum creatinine and serum potassium on the variance of the digoxin plasma levels was computed by multiple linear regression. The multiple correlation coefficient was r = 0.666, the coefficient of determination (100 r2) being 44.4%. Therefore 44.4% of the total variance could be explained by these variables. Individual variables accounted for the following percentages of the total variance: serum creatinine 29.1%; maintenance dose 14.5%; age 4.3%; and reciprocal of body weight 3.9%.