Single-dose pharmacokinetics of ampicillin and tobramycin administered by hypodermoclysis in young and older healthy volunteers

1To test the feasibility of administering antibiotics by subcutaneous infusion to the elderly, we compared the pharmacokinetics of tobramycin (single dose of 80 mg) given by hypodermoclysis (HDC) with the kinetics of the antibiotic injected intravenously (i.v.) in 10 young (<50 years old) and 10 elderly (>65 years old) healthy volunteers. Similar studies were performed with ampicillin (single dose of 1 g) in 12 young and 10 older healthy volunteers. 2Compared with the i.v. route, HDC delayed the time to reach the maximal plasma concentration (t_max) of tobramycin in young volunteers: 32±6 (s.d.) min vs 88±46, P<0.005, and older volunteers: 27±4 min vs 89±15, P<0.005. Administration of the antibiotics by HDC was well tolerated. The plasma concentration of tobramycin 30 min after the end of infusion (C₆₀) was lower (P<0.05) following HDC than after the i.v. route in both young, 2.2±0.7 vs 3.5±0.8 μg ml⁻¹, and elderly subjects, 2.2±0.8 vs 3.8±0.9. μg ml⁻¹. 3The area under the curve (AUC) of tobramycin given by HDC was slightly smaller than when given i.v., i.e. in young subjects: 740±225 (s.d.) vs 893±223 μg ml⁻¹ min, NS, and in the elderly: 980±228 vs 1056±315 μg ml⁻¹ min, NS. 4When ampicillin was administered by HDC, the t_max was also delayed in young volunteers: 45±18 vs 23±6 min, and in the elderly: 49±18 vs 27±4 min, P<0.005, the AUC was greater by HDC than i.v. in the young volunteers: 4527±1658 μg ml⁻¹ min vs 3810±1033 μg ml⁻¹ min and in the elderly: 6795±2094 μg ml⁻¹ min vs 4217±1518 μg ml⁻¹ min, and the C₆₀ was higher by HDC in the young: 27±7 vs 24±9 μg ml⁻¹, and in the elderly: 32±9 vs 23±11 μg ml⁻¹, P<0.05. 5In conclusion, HDC delays the entry of the antibiotic into the systemic circulation, but did not affect the amount available. HDC was well tolerated and could become an adequate method for antibiotic administration to the elderly.     

The effect of omeprazole on the pharmacokinetics of metronidazole and hydroxymetronidazole in human plasma, saliva and gastric juice

Aims To evaluate the effect of omeprazole on the pharmacokinetics of metronidazole and hydroxymetronidazole in plasma, gastric juice and saliva following intravenous infusion or oral dosing of metronidazole. Methods Eight volunteers received single doses of metronidazole (400 mg) intravenously and orally, whilst taking placebo or omeprazole (40 mg, twice daily for 5 days) in a randomized 4-way crossover study. Metronidazole and hydroxymetronidazole concentrations in plasma, saliva and gastric juice samples were determined by h.p.l.c. Pharmacokinetic parameters for metronidazole and hydroxymetronidazole were calculated, and the significance of the mean differences in parameters between omeprazole and placebo co-administration was assessed using a two-tailed, paired t-test. Results There were no significant differences (P<0.05) in any of the plasma or saliva pharmacokinetic parameter values for metronidazole between volunteers receiving omeprazole or placebo when metronidazole was administered either as an intravenous infusion or orally. Following intravenous administration of metronidazole to the placebo group and omeprazole treated group respectively, the gastric transfer of metronidazole was significantly reduced from 15.5±10.4% to 2.6±1.0% of the dose (P=0.007; 95% CI of difference 4.8 to 21.0) with concomitant changes in the metronidazole AUC (from 77.5±18.0 μmol l⁻¹ h to 352.6±182.1 μmol l⁻¹ h; P=0.0003; 95% CI of difference 127.6 to 422.7), C_max (from 61.4±26.5 μmol l⁻¹ to 271.8±104.3 μmol l⁻¹; P=0.0001; 95% CI of difference 118.6 to 302.1). Similarly, the gastric juice AUC of hydroxymetronidazole was significantly reduced from 3.2±1.9 μmol l⁻¹ h to 1.5±0.8 μmol l⁻¹ h of the dose (P=0.0043; 95% CI of difference 0.4 to 3.0) with a concomitant change in C_max (from 5.0±2.5 μmol l⁻¹ to 3.0±1.2 μmol l⁻¹; P=0.0007; 95% CI of difference 0.7 to 3.4). Conclusions Omeprazole had little effect on the plasma and salivary pharmacokinetics of metronidazole (or its hydroxymetabolite) after intravenous or oral administration, but it did have a substantial effect on the pharmacokinetics of metronidazole and hydroxymetronidazole in gastric juice.     

Morphine, morphine-6-glucuronide and morphine-3-glucuronide pharmacokinetics in newborn infants receiving diamorphine infusions

1The pharmacokinetics of morphine, morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G) were studied in 19 ventilated newborn infants(24–41 weeks gestation) who were given a loading dose of 50 μg kg⁻¹ or 200 μg kg⁻¹ of diamorphine followed by an intravenous infusion of 15 μg kg⁻¹ h⁻¹ of diamorphine. Plasma concentrations of morphine, M3G and M6G were measured during the accrual to steady-state and at steady state of the diamorphine infusion. 2Following both the 50 μg kg⁻¹ or 200 μg kg⁻¹ loading doses the mean steady-state plasma concentration (±s.d.) of morphine, M3G and M6G were 86±52 ng ml⁻¹, 703±400 ng ml⁻¹ and 48±28 ng ml⁻¹ respectively and morphine clearance was found to be 4.6±3.2 ml min⁻¹ kg⁻¹. 3M3G formation clearance was estimated to be 2.5±1.8 ml min⁻¹ kg⁻¹, and the formation clearance of M6G was estimated to be 0.46±0.32 ml min⁻¹ kg⁻¹. 4M3G metabolite clearance was 0.46±0.60 ml min⁻¹ kg⁻¹, the elimination half-life was 11.1±11.3 h and the volume of distribution was 0.55±1.13 l kg⁻¹. M6G metabolite clearance was 0.71±0.36 ml min⁻¹ kg⁻¹, the elimination half-life was 18.2±13.6 h and the volume of distribution was 1.03±0.88 l kg⁻¹. 5No significant effect of the loading dose (50 μg kg⁻¹ or 200 μg kg⁻¹) on the plasma morphine or metabolite concentrations or their derived pharmacokinetic parameters was found. 6We were unable to identify correlations between gestational age of the infants and any of the determined pharmacokinetic parameters. 7M3G:morphine and M6G:morphine steady-state plasma concentration ratios were 11.0±10.8 and 0.8±0.8, respectively. 8The metabolism of morphine in neonates, in terms of the respective contributions of each glucuronide pathway, was similar to that in adults.     

The involvement of CYP1A2 and CYP3A4 in the metabolism of clozapine

Aims Clozapine (CLZ), an atypical neuroleptic with a high risk of causing agranulocytosis, is metabolized in the liver to desmethylclozapine (DCLZ) and clozapine N-oxide (CLZ-NO). This study investigated the involvement of different CYP isoforms in the formation of these two metabolites. Methods Human liver microsomal incubations, chemical inhibitors, specific antibodies, and different cytochrome P450 expression systems were used. Results K_m and V_max values determined in human liver microsomes were lower for the demethylation (61±21 μm, 159±42 pmol min⁻¹ mg protein⁻¹ mean±s.d.; n=4), than for the N-oxidation of CLZ (308±1.5 μm, 456±167pmol min⁻¹ mg protein⁻¹; n=3). Formation of DCLZ was inhibited by fluvoxamine (53±28% at 10 μm ), triacetyloleandomycin (33±15% at 10 μm ), and ketoconazole (51±28% at 2 μm ) and by antibodies against CYP1A2 and CYP3A4. CLZ-NO formation was inhibited by triacetyloleandomycin (34±16% at 10 μm ) and ketoconazole (51±13% at 2 μm ), and by antibodies against CYP3A4. There was a significant correlation between CYP3A content and DCLZ formation in microsomes from 15 human livers (r=0.67; P=0.04). A high but not significant correlation coefficient was found for CYP3A content and CLZ-NO formation (r=0.59; P=0.09). Using expression systems it was shown that CYP1A2 and CYP3A4 formed DCLZ and CLZ-NO. K_m and V_max values were lower in the CYP1A2 expression system compared to CYP3A4 for both metabolic reactions. Conclusions It is concluded that CYP1A2 and CYP3A4 are involved in the demethylation of CLZ and CYP3A4 in the N-oxidation of CLZ. Close monitoring of CLZ plasma levels is recommended in patients treated at the same time with other drugs affecting these two enzymes.     

Effect of simvastatin on cyclosporine unbound fraction and apparent blood clearance in heart transplant recipients

Aims To investigate the effects of lipid lowering therapy on the fraction unbound and dosage requirement of cyclosporine in heart transplant recipients. Methods Cyclosporine fraction unbound (fu) was measured ex vivo in plasma obtained from heart transplant recipients (n=12) before and after lipid lowering treatment, using equilibrium dialysis. Cyclosporine trough concentration data were also collected from cardiac transplant recipients (n=32) who received simvastatin for the treatment of hyperlipidaemia. Cyclosporine daily dosage and total concentration (monoclonal FPIA method) were recorded for periods up to 6 months before and after simvastatin administration. The total number of dose rate-concentration observations was 172 before and 135 after simvastatin administration respectively. Using a population pharmacokinetic approach (implemented in P-PHARM software) the ratio of dose rate to trough concentration at steady state (DR/C_sstrough ), an estimation of apparent clearance, was determined. The posterior Bayesian estimate of DR/C_sstrough was calculated for each patient before and after simvastatin administration. Results The mean fu increased by 29%, from 1.40±0.1% (mean±s.d.) to 1.82±0.22% after simvastatin administration (P<0.01). Mean trough concentrations of cyclosporine in whole blood were 349 μg l⁻¹ before and 242 μg l⁻¹ after simvastatin administration (P<0.0001). The mean cyclosporine daily dosage was 2.87 mg kg⁻¹ and 2.33 mg kg⁻¹ (NS), before and after simvastatin administration respectively. The average cyclosporine DR/C_sstrough was significantly increased from 24.5 l h⁻¹ before to 28.9 l h⁻¹ after simvastatin administration (P<0.05). Furthermore the median increase in cyclosporine DR/C_sstrough was 18 l h⁻¹ (−3.1 to 42.1 l h⁻¹, interquartile range). Conclusions Cyclosporine fraction unbound and clearance are increased following co-administration of lipid lowering agents, necessitating closer monitoring of cyclosporine total blood concentration when lipid lowering agents are administered concomitantly with cyclosporine.     

Non-linear pharmacokinetics of high-dose intravenous verapamil

Aims In an attempt to reverse multidrug resistance, in a recent trial of verapamil in association with doxorubicin, we used escalating doses of continuous intravenous (i.v.) verapamil under close haemodynamic monitoring. We report the pharmacokinetics of escalating doses of verapamil. Methods We studied nine patients [ seven males, two females; median age 46 years (range, 31–57)] with advanced adenocarcinoma of the colon and normal renal, hepatic, and cardiac functions. After a loading dose (0.15 mg kg⁻¹ followed by 12 h continuous i.v. infusion at 0.20 mg kg⁻¹ h⁻¹ ), the infusion rate (ko) of verapamil was increased every 24 h (0.25, 0.30, 0.35, and 0.40 mg kg⁻¹ h⁻¹ ). The highest rate was maintained for 48 h. Doxorubicin was given as a continuous i.v. infusion from 12 to 108 h (n=4) or 60 to 108 h (n=5). Blood samples and urine collections were taken every 12 h. Verapamil and nor-verapamil were assayed by high performance liquid chromatography. We calculated systemic clearance of verapamil (CL=ko/C_ss ) and renal clearance (CLr) of verapamil and nor-verapamil. The C_ssvs rate relationship was fitted to a Michaelis-Menten equation: C_ss=ko(K_m+C_ss )/(V V_m ). Results CL was dose-dependent and in all nine patients a significant reduction in CL was observed over the dose range (mean CL±s.d. were 0.51±0.31, 0.38±0.16, 0.32±0.18, and 0.27±0.11 l h⁻¹ kg⁻¹, respectively, at 0.25, 0.30, 0.35, and 0.40 mg kg⁻¹ h⁻¹; P=0.0001). C_ss increased more than proportionally to the dose rate and the C_ssvs rate relationship was best defined by a Michaelis-Menten equation (K_m=730 μg l⁻¹; V V_m=0.55 mg kg⁻¹ h⁻¹ ), (r=0.994; P=0.006). CLr of verapamil and nor-verapamil was not saturable but the contribution to the elimination was only 2 to 4% of the dose. Conclusions These findings suggest a non-linear, capacity-limited metabolic clearance of high-dose verapamil. Using escalating infusion rates, high verapamil concentrations (1500–2500 ng ml⁻¹ ) were achieved without major toxicity. Saturable clearance may cause higher bioavailability and slower elimination of verapamil after acute oral overdoses.     

Pharmacokinetic– pharmacodynamic analysis of the role of CYP2C19 genotypes in short-term rabeprazole-based triple therapy against Helicobacter pylori

AIMS

The aim was to explore the role of CYP2C19 polymorphism in short-term rabeprazole-based triple therapy against Helicobacter pylori infection.

METHODS

Patients with H. pylori infection were tested for CYP2C19 genotype as poor metabolizers (PMs) or extensive metabolizers (EMs, homozygous EM or heterozygous EM) and given rabeprazole for 7 days. Antibiotics (clarithromycin and amoxicillin) were given on days 1–4, days 4–7, or days 1–7. A direct link model with an effect compartment was used in the population pharmacokinetic–pharmacodynamic analysis. The status of H. pylori infection was evaluated.

RESULTS

Rabeprazole clearance was lower in CYP2C19 PMs than in EMs (with average values of 10.7 vs. 16.8 l h⁻¹ in PMs and EMs, respectively), resulting in higher plasma levels in the former group. The values of EC₅₀ and k_eo of gastrin response increased with multiple doses of rabeprazole. The k_eo values were lower in CYP2C19 PMs than in EMs on day 1 (0.012 vs. 0.017 × 10⁻⁴ l min⁻¹), and higher than in EMs on day 4 (0.804 vs. 0.169 × 10⁻⁴ l min⁻¹) of rabeprazole treatment. The predicted gastrin-time profile showed a higher response in CYP2C19 PMs than in EMs on days 4 and 7. Helicobacter pylori was eradicated in all CYP2C19 PMs except in one patient infected by a resistant strain. In contrast, in CYP2C19 EMs the eradication rates ranged from 58 to 85%.

CONCLUSIONS

CYP2C19 genotypes play a role in H. pylori eradication therapy. Rabeprazole-based short-term triple therapy may be applicable in CYP2C19 PMs for H. pylori eradication.     

Dopamine natriuresis in salt-repleted, water-loaded humans: a dose-response study

Aims The purpose of the present study was to define the dose-response relationship between exogenous dopamine and systemic haemodynamics, renal haemodynamics, and renal excretory function at infusion rates in the range 0 to 12.5 μg kg⁻¹ min⁻¹ in normal volunteers. Methods While undergoing water diuresis, eight subjects were infused with 0, 1, 2, 3, 5, 7.5, 10 or 12.5 μg of dopamine kg⁻¹ min⁻¹ over 2 h in a randomized and double-blind fashion. On each study day, renal clearance studies were performed during a 1 h baseline period and subsequently during the second 1 h infusion period. Lithium clearance (CL_Li ) was used to estimate proximal tubular outflow. Results Cardiac output increased with the four highest doses. Mean arterial pressure followed a biphasic pattern with a decrease during the two lowest doses and a dose-dependent increase from the 7.5 μg kg⁻¹ min⁻¹ dose onwards. Effective renal plasma flow increased with all doses of dopamine, but peaked with the 3 μg kg⁻¹ min⁻¹ infusion rate [ from 617 (585–649) ml min⁻¹ with placebo to 915 (824–1006) ml min⁻¹ (means with 95% CI, P<0.001)]. None of the doses changed glomerular filtration rate (GFR). Sodium clearance (CL_Na ) and CL_Li were elevated with the four lowest doses but increased further from 7.5 μg kg⁻¹ min⁻¹ onwards. Compared with placebo, the percentage increase in CL_Na with increasing dose was 77 (5–159), 93 (13–172), 107 (24–190), 121 (60–181), 253 (65–441), 284 (74–494), and 212 (111–312) %, respectively. There were only small, inconsistent decreases in absolute proximal reabsorption rate (APR=GFR-CL_Li ). Fractional distal reabsorption of sodium (FDR_Na=(CL_Li-CL_Na )/CL_Li ) decreased with all doses, reaching its nadir with 7.5 μg kg⁻¹ min⁻¹ [from 95.9 (94.6–97.2) % with placebo to 91.5 (90.0–93.0) % (P<0.01)] whereafter a flat dose-response curve was observed. Conclusions In conclusion, the renal vasodilating effect of dopamine was maximal with 3 μg kg⁻¹ min⁻¹. The dose-dependent attenuation seen with higher doses is consistent with an increased α-adrenergic stimulation opposing the effect on dopaminergic receptors. The present CL_Li studies confirm that dopamine increases proximal tubular outflow. The results suggest that the natriuretic effect of depressor doses of dopamine was primarily caused by attenuation of the increase in distal sodium reabsorption normally seen after an increase in proximal tubular outflow. Pressor doses further increased sodium excretion, indicating the presence of pressure natriuresis at these high doses.     

Comparison of nitroprusside and nitroglycerin in inhibition of angiotensin II and other vasoconstrictor-mediated contraction in human coronary bypass conduits

Aims To compare the effect of nitroprusside (SNP) and nitroglycerin (NTG) on angiotensin II (ANGII), endothelin-1 (ET-1), and α₁-adrenoceptor (phenylephrine, PE)-mediated contraction in internal mammary artery (IMA). Methods Human IMA segments (n=120) taken from 37 patients were studied. Concentration-relaxation curves for SNP and NTG were established in IMA precontracted with these vasoconstrictors. Concentration-contraction curves were also constructed in IMA rings incubated with SNP and NTG (0.1 and 1 μm ) for 10 min. Results Both SNP and NTG caused full relaxation with similar EC₅₀ s except NTG was four-fold more potent than SNP in PE-induced contraction (−7.92±0.06 vs−7.32±0.2 log m, mean±s.e. mean, P<0.01; 95% confidence interval for the difference of the means: 0.19, 1.01 log m ). Pretreatment with SNP (0.1 and 1 μm ) significantly depressed the contraction by ANGII from 56.6±7.7% (of 100 mm K⁺-contraction) to 18.3±8.6% and 3.9±2.1% (P=0.0001). In four rings treated with SNP, the contraction to ANGII was abolished whereas NTG did not depress ANGII-mediated contraction. Pretreatment with SNP (1 μm ), but not NTG, significantly depressed the magnitude of the PE-induced contraction from 4.7±1.2 to 1.7±0.4 g (P<0.05). Treatment with both SNP and NTG significantly increased the EC₅₀ (−5.09±0.17 log m, P=0.0007 for SNP and −5.40±0.06 log M, P=0.02 for NTG). Pretreatment with SNP did not significantly change either the magnitude or the EC₅₀ of the ET-1-induced contraction. Conclusions SNP may be advantageous compared with NTG in preventing coronary arterial graft contraction. However, once grafts have constricted to ANGII, α₁-adrenoceptor agonists, and ET-1, NTG may be only marginally advantageous.     

Comparison of the effects of clonidine on tyramine- and methoxamine-evoked mydriasis in man

1 It has been reported previously that clonidine can potentiate tyramine-evoked mydriasis on the pain-free side of cluster headache patients. We examined whether a single oral dose of clonidine (200 μg) can also potentiate tyramine-evoked mydriasis in healthy subjects, using mydriasis to methoxamine, a directly acting sympathomimetic amine, as a control. 2 Eight healthy male volunteers participated in four weekly sessions. In the first two sessions (Experiment 1) the effect of clonidine or placebo on the mydriasis to tyramine hydrochloride eyedrops (75 mm; 2×10 μl), and in the last two sessions (Experiment 2) the effect of clonidine or placebo on the mydriasis to methoxamine hydrochloride eyedrops (20 mm; 2×10 μl) was examined. In both experiments subjects were allocated to drugs and sessions according to a double-blind balanced design. In both experiments, pupil diameter of both the treated and the untreated eyes was recorded in standard ambient light and in the dark, before, and 2 h after clonidine/placebo, via binocular infrared television pupillometry. Salivation (dental roll technique), systolic and diastolic blood pressure (sitting), heart rate, and self-ratings of mood and feelings (visual analogue scales), were also measured before, and 2 h after the ingestion of clonidine or placebo. 3 Both tyramine and methoxamine produced a significant mydriasis, which was more prominent in the light condition (change in resting pupil size; mm±s.e.mean: tyramine/light 1.05±0.28; tyramine/dark: 0.73±0.15; methoxamine/light: 1.65±0.28; methoxamine/dark: 0.85±0.15). Clonidine produced a significant miosis in the untreated eye which was more prominent in the light condition (change in resting pupil size; mm±s.e.mean: Experiment 1, light: −1.34±0.19; Experiment 1, dark: −0.46±0.1; Experiment 2, light −0.97±0.18; Experiment 2, dark: −0.29±0.17). Clonidine had no significant effect on either tyramine- or methoxamine-evoked mydriasis. 4 In agreement with previous reports, clonidine significantly reduced salivation (g, mean±s.e.mean; Experiment 1: −0.84±0.22; Experiment 2: −0.55±0.11), systolic blood pressure (mm Hg; Experiment 1: −17.5±3.76; Experiment 2: −23.38±4.67), diastolic blood pressure (mm Hg; Experiment 2: −12.38±2.05), alertness (mm; Experiment 2: −24.19±5.40), and anxiety (mm; Experiment 1: −13.82±4.60), indicating the presence of pharmacodynamically effective tissue levels of the drug. 5 These results show that a single oral dose (200 μg) of clonidine causes significant miosis in human subjects, and fails to potentiate tyramine-evoked mydriasis. This indicates that the pupil on the asymptomatic side of cluster headache patients is affected differently from the pupils of healthy volunteers by tyramine and/or clonidine.     

Enzyme kinetic modelling as a tool to analyse the behaviour of cytochrome P450 catalysed reactions: application to amitriptyline N-demethylation

1To determine kinetic parameters (V_max, K_m) for cytochrome P450 (CYP) mediated metabolic pathways, nonlinear least squares regression is commonly used to fit a model equation (e.g., Michaelis Menten [MM]) to sets of data points (reaction velocity vs substrate concentration). This method can also be utilized to determine the parameters for more complex mechanisms involving allosteric or multi-enzyme systems. Akaike''s Information Criterion (AIC), or an estimation of improvement of fit as successive parameters are introduced in the model ( F-test), can be used to determine whether application of more complex models is helpful. To evaluate these approaches, we have examined the complex enzyme kinetics of amitriptyline (AMI) N-demethylation in vitro by human liver microsomes. 2For a 15-point nortriptyline (NT) formation rate vs substrate (AMI) concentration curve, a two enzyme model, consisting of one enzyme with MM kinetics (V_max=1.2 nmol min⁻¹ mg⁻¹, K_m=24 μm) together with a sigmoidal component (described by an equation equivalent to the Hill equation for cooperative substrate binding; V_max=2.1 nmol min⁻¹ mg⁻¹, K′=70 μm; Hill exponent n=2.34), was favoured according to AIC and the F-test. 3Data generated by incubating AMI under the same conditions but in the presence of 10 μm ketoconazole (KET), a CYP3A3/4 inhibitor, were consistent with a single enzyme model with substrate inhibition (V_max=0.74 nmol min⁻¹ mg⁻¹, K_m=186 μm, K₁=0.0028 μm⁻¹). 4Sulphaphenazole (SPA), a CYP2C9 inhibitor, decreased the rate of NT formation in a concentration dependent manner, whereas a polyclonal rat liver CYP2C11 antibody, inhibitory for S-mephenytoin 4′-hydroxylation in humans, had no important effect on this reaction. 5Incubation of AMI with 50 μm SPA resulted in a curve consistent with a two enzyme model, one with MM kinetics (V_max=0.72 nmol min⁻¹ mg⁻¹, K_m=54 μm) the other with ‘Hill-kinetics’ (V_max=2.1 nmol min⁻¹ mg⁻¹, K′=195 μm; n=2.38). 6A fourth data-set was generated by incubating AMI with 10 μm KET and 50 μm SPA. The proposed model of best fit describes two activities, one obeying MM-kinetics (V_max=0.048 nmol min⁻¹ mg⁻¹, K_m=7 μm) and the other obeying MM kinetics but with substrate inhibition (V_max=0.8 nmol min⁻¹ mg⁻¹, K_m=443 μm, K₁=0.0041 μm⁻¹). 7The combination of kinetic modelling tools and biological data has permitted the discrimination of at least three CYP enzymes involved in AMI N-demethylation. Two are identified as CYP3A3/4 and CYP2C9, although further work in several more livers is required to confirm the participation of the latter.     

The effects of combined treatment with β1-selective receptor antagonists and lipid-lowering drugs on fat metabolism and measures of fatigue during moderate intensity exercise: a placebo-controlled study in healthy subjects

Aims We examined the effects of different combinations of β₁-selective adrenoceptor blockers and lipid-lowering drugs, on fat metabolism and fatigue during moderate intensity exercise in 14 healthy young volunteers. Methods The study was a randomized crossover design, each subject completing 5, 90 min walks at 50% of predetermined maximal oxygen uptake (VO₂ max), one following each 3 day treatment period with either: atenolol 100 mg and bezafibrate 400 mg, atenolol 100 mg and fluvastatin 40 mg, metoprolol CR 100 mg and bezafibrate 400 mg, metoprolol CR 100 mg and fluvastatin 40 mg, or placebo. Results Plasma free fatty acid (FFA) concentration during exercise was significantly reduced on all treatments, in comparison with placebo, P=0.0001. Following 90 min of exercise FFA levels were as follows: placebo 573 μmol l⁻¹ (105–1041), metoprolol CR+fluvastatin 277 μmol l⁻¹ (0–647), metoprolol CR+bezafibrate 182 μmol l⁻¹ (0–396), atenolol+fluvastatin 211 μmol l⁻¹ (0–511), and atenolol+bezafibrate 123 μmol l⁻¹ (0–352). Total fat oxidation during exercise was also reduced on all treatments in comparison with placebo: 38.1% (2–74), compared with 29.1% (0–61) on metoprolol CR+fluvastatin, P=0.02, 26.2% (2–51) on metoprolol CR+bezafibrate, P=0.002, 25.5% (3–48) on atenolol+fluvastatin, P=0.009, and 22.8% (0–47) on atenolol+bezafibrate treatment, P=0.0002. Plasma ammonia concentration was elevated on all treatments during exercise in comparison with placebo. After 90 min of exercise, plasma ammonia levels were as follows: placebo 37 μmol l⁻¹ (0–84), metoprolol CR+fluvastatin 56 μmol l⁻¹ (2–110), metoprolol CR+bezafibrate 79 μmol l⁻¹ (0–167), atenolol+fluvastatin 90 μmol l⁻¹ (10–170), and atenolol+bezafibrate 100 μmol l⁻¹ 26–174). In comparison with placebo, metoprolol CR+fluvastatin had the least adverse impact on measures of perceived exertion and the ‘feeling scale’ during exercise. Metoprolol CR+bezafibrate, atenolol+fluvastatin, and atenolol+bezafibrate treatments had greater adverse effects, particularly on perceived ‘cardiorespiratory effort’ and ‘feeling scale’ scores. Conclusions In healthy volunteers, combinations of β₁-selective blockers and lipid-lowering drugs were associated with significant reductions in fat metabolism, increased plasma ammonia levels, and raised the perception of effort during exercise, in comparison with placebo. Metoprolol CR+fluvastatin had the least effect, combinations metoprolol CR+bezafibrate and atenolol+fluvastatin had intermediate effects, and atenolol+bezafibrate had the most adverse effect.     

Inhibition of vasoconstriction by potassium channel opener aprikalim in human conduit arteries used as bypass grafts

Aims Potassium channel openers (KCOs) are of potential therapeutic value. Little is known about the effect of these drugs on human conduit arteries used as coronary bypass grafts. The purpose of this study was to determine the effect of the KCO aprikalim (RP52891) on human arteries used as coronary bypass grafts with emphasis on the possible difference in the inhibitory effect on depolarizing agent-mediated rather than receptor-mediated contraction. Methods Human internal mammary artery segments (IMA, n=88) taken from 28 patients were studied. Concentration-relaxation curves for aprikalim were established in IMA precontracted with three vasoconstrictors (K⁺, U46619, and phenylephrine). In IMA rings incubated with aprikalim (1 or 30 μm ) for 10 min concentration-contraction curves for the three vasoconstrictors were constructed. Results Aprikalim-induced relaxation was less in K⁺ (37.3±6.4%) than in U46619 (80.2±7.7%, P=0.002), or phenylephrine (67.5±7.0%, P=0.038) -precontracted IMA. The EC₅₀ for K⁺-(−5.40±0.12 log m ) was significantly higher than that for phenylephrine (−6.43±0.30 log m, P=0.007) but not significant compared with that for U46619 (−5.81±0.11, P >0.05). Pretreatment with aprikalim depressed the contraction by phenylephrine from 140.6±27.6% to 49.3±14.1% (P=0.002) and shifted the EC₅₀ 11.0-fold higher in rings treated with 1 μm aprikalim (P=0.007). Treatment of aprikalim did not significantly reduce the K⁺ and U46619-induced contraction (P >0.05) but shifted the concentration-contraction curves rightward (2.8-fold higher for K⁺, P<0.05 and 2.2-fold higher for U46619, P<0.05). Conclusions This study demonstrates that aprikalim has vasorelaxant effects in human conduit arteries used as coronary artery bypass grafts contracted by a variety of vasoconstrictors and this effect is vasoconstrictor-selective with greater potency for α₁-adrenoceptor agonists than for depolarizing agent K⁺. These findings provide information on the possible use of this KCO in various clinical settings.     

The effects of co-administration of benzhexol on the peripheral pharmacokinetics of oral levodopa in young volunteers

1 The effects of benzhexol on the absorption and pharmacokinetics of an oral dose of levodopa have been studied in 10 young healthy volunteers. Subjects were given a suspension of levodopa (250 mg) 90 min after either benzhexol (5 mg) or placebo in a randomized cross over design with doses separated by at least 1 week; on each occasion carbidopa was given 1 h before and 5 h after the dose of levodopa. Soluble paracetamol and radiolabelled DTPA were given with the levodopa as markers of gastric emptying. 2 Most subjects showed two peaks in the levodopa plasma concentration–time curve on the placebo day, with the second minor peak occurring 1–2 h after the dose. After benzhexol administration all subjects showed two or more peak levodopa concentrations in plasma. Benzhexol administration caused a significant decrease in the maximum concentration (43%; P<0.05) of the initial peak and an increase (22%; P<0.1) in the maximum concentration of the second peak. This change in absorption profile caused by benzhexol significantly altered the ratios of the second peak compared with the initial peak for both the maximum concentrations (P<0.02) and for the AUC values (P<0.05). Benzhexol administration did not affect the total AUC of levodopa (7.30±1.09 vs 7.19±1.26 μg ml⁻¹ h; means±s.d.). 3 The plasma concentration–time curves for paracetamol showed similar profiles to those for levodopa and the ratios of the peak concentrations and AUC values for the second peak compared with the initial peak were increased significantly by benzhexol administration (P<0.05). The total AUC of paracetamol was not affected by benzhexol administration (39.4±8.2 vs 40.0±8.9 μg ml⁻¹ h; mean±s.d.) 4 Benzhexol altered the gastric emptying profile, shown by γ-scintigraphy, with a reduced extent of initial emptying prior to the establishment of the plateau which is characteristic of levodopa administration in the fasting state. In consequence the ratio of the second to the initial phase of emptying was significantly higher (P<0.01) following benzhexol treatment. 5 Benzhexol reduces the initial phase of gastric emptying after a dose of levodopa so that there is a decrease in the initial peak and a greater proportion of the dose is absorbed subsequently following the second phase of gastric emptying which occurs approximately 1 h later. Theoretically, this altered concentration-time profile could be an advantage for some patients with Parkinson''s disease.     

Pyrazinamide blood concentrations in children suffering from tuberculosis: a comparative study at two doses

Aims

To evaluate the pharmacokinetics and pharmacodynamic indices of pyrazinamide at doses of 15 and 25 mg kg⁻¹ in children suffering from tuberculosis.

Methods

Twenty children with tuberculosis received pyrazinamide at a single dose of 25 mg kg⁻¹ (group I) and 15 mg kg⁻¹ (group II). Serial blood samples were collected and the drug concentrations were analyzed spectrophotometrically. The pharmacokinetic parameters were calculated and the duration of time for which pyrazinamide concentrations in serum remained above the pyrazinamide inhibitory concentrations of 20 μg ml⁻¹ and 25 μg ml⁻¹ was studied.

Results

The mean peak serum concentration was 42.4 ± 3.3 μg ml⁻¹ (95% CI ± 6.5) and 38.6 ± 3.9 μg ml⁻¹ (95% CI ± 7.7) in groups I and II, respectively. The elimination half-life was 9.3 ± 1.3 h and 10.5 ± 2.3 h (P = 0.6) and clearance was 0.06 ± 0.01 l h⁻¹ kg⁻¹ and 0.04 ± 0.01 l h⁻¹ kg⁻¹ (P = 0.08) in groups I and II, respectively. Pharmacokinetic parameters and PKPD indices were comparable with both the doses.

Conclusions

The study indicates that comparable serum concentrations of pyrazinamide are attained with 25 mg kg⁻¹ and 15 mg kg⁻¹ doses in children. The elimination half-life was longer and volume of distribution greater in children than in the adult population.

What is already known about this subject

• Pyrazinamide is recommended in doses varying from 15 to 40 mg kg⁻¹. The most commonly used average daily dose is 25 mg kg⁻¹. Its use is associated with dose dependent hepatotoxicity.
• Lower doses are not used because of lack of pharmacokinetic data especially in children. There is only one detailed study of pyrazinamide in children at a dose of 35 mg kg⁻¹.

What this study adds

• This is the first study evaluating serum concentrations of pyrazinamide in children at a dose of 15 mg kg⁻¹ which is on the lower side of the recommended dose. The study also compared the serum concentrations and pharmacokinetics achieved with this dose with the widely used dose of 25 mg kg⁻¹ in children suffering from tuberculosis.
• The pharmacokinetics and pharmacodynamic indices of pyrazinamide were comparable with the 25 and 15 mg kg⁻¹ doses.

     

The pharmacokinetics of methadone in healthy subjects and opiate users

Aims There is some evidence that monitoring methadone plasma concentration may be of benefit in dosage adjustment during methadone maintenance therapy for heroin (opiate) dependence. However, the kinetics of oral methadone are incompletely characterized. We attempted to describe the latter using a population approach combining intensive 57 h sampling data from healthy subjects with less intensive sparse 24 h data from opiate users. Methods Single oral doses of rac-methadone were given to 13 drug-naive healthy subjects (7 men and 6 women) and 17 opiate users beginning methadone maintenance therapy (13 men and 4 women). Plasma methadone concentrations were measured by h.p.l.c. Kinetic analysis was performed using the P-Pharm software. Results Comparison of kinetic models incorporating mono- or biexponential disposition functions indicated that the latter best represented the data. The improvement was statistically significant for the data from healthy subjects whether the full 57 h or truncated 24 h profiles were used (P<0.031 and P<0.024, respectively), while it was of borderline significance for the more variable data from opiate users (P=0.057) or for pooled (healthy subjects and opiate users) data (P=0.066). The population mean oral clearance of methadone was 6.9±1.5 s.d. l h⁻¹ (5.3±1.2 s.d. l h⁻¹ using 0–24 h data) in the healthy subjects. The results of separate analyses of the data from opiate users and healthy subjects were in contrast with those obtained from pooled data analysis. The former indicated a significantly lower clearance for opiate users (3.2±0.3 s.d. l h⁻¹, P<0.001); 95% CI for the difference=−3 to −6 l h⁻¹ and no difference in the population mean values of V /F (212±27 s.d. l and 239±121 s.d. l, P=0.15), while according to the latter analysis addiction was a covariate for V /F but not for oral clearance. A slower absorption of methadone in opiate users was indicated from the analysis of both pooled and separate data. The median elimination half-life of methadone in healthy subjects was 33–46 h depending on the method used to calculate this parameter. Conclusions Estimates of the long terminal elimination half-life of methadone (33–46 h in healthy subjects and, possibly, longer in opiate users) indicated that accurate measurement of this parameter requires a duration of sampling longer than that used in this study. Our analysis also suggested that parameters describing plasma concentrations of methadone after a single oral dose in healthy subjects may not be used for predicting and adjusting dosage in opiate users receiving methadone maintenance therapy unless coupled with feedback concentration monitoring techniques (for example Bayesian forecasting).     

Pharmacokinetics and response of obese patients with chronic hepatitis C treated with different doses of PEG-IFN α-2a (40KD) (PEGASYS®)

AIMS

To evaluate whether higher doses of peginterferon α-2a (40KD) [PEG-IFN α-2a (40KD)] can compensate for lower exposure observed among obese patients with chronic hepatitis C (CHC) treated with the standard dose of PEG-IFN α-2a (40KD).

METHODS

Noncirrhotic, obese (body mass index ≥30 kg m⁻²) patients with CHC participated in a single-centre, open-label study. Patients were randomized to 180 or 270 µg week⁻¹ PEG-IFN α-2a (40KD) + ribavirin (1000/1200 mg day⁻¹) for 48 weeks. Blood samples were collected predose and up to 168 h after the first dose and at week 12 for pharmacokinetic analysis. Trough serum concentrations (C_trough) were determined up to week 24.

RESULTS

In the 180 µg week⁻¹ group mean ± SD steady-state (week 12) estimates of AUC_0–168 (ng h⁻¹ ml⁻¹), C_max (ng ml⁻¹) and CL/F (l h⁻¹) were 2154 ± 919, 13.8 ± 6.7 and 0.102 ± 0.051, respectively. In the 270 µg week⁻¹ group, estimates were 3374 ± 1844, 23.4 ± 10.7 and 0.090 ± 0.042, respectively. The mean (range) C_trough (ng ml⁻¹) was 11.2 (4.4–18.5) in the 180 µg week⁻¹ group and 16.1 (0.4–44.2) in the 270 µg week⁻¹ group. Overall, 14 of 20 (70%) and 16 of 20 (80%) patients in the 180 µg week⁻¹ and 270 µg week⁻¹ groups were infected with hepatitis C virus genotype 1 or 4. In the 180 µg week⁻¹ and 270 µg week⁻¹ groups 14 of 20 (70%) and 15 of 19 (79%) patients, respectively, achieved a sustained viral response. Safety was similar between groups.

CONCLUSIONS

Mean PEG-IFN α-2a (40KD) exposure was dose proportional from 180 to 270 µg week⁻¹. Increasing PEG-IFN α-2a (40KD) from 180 to 270 µg week⁻¹ achieves higher serum drug exposure in obese patients.     

A pharmacokinetic and pharmacodynamic interaction study between nebivolol and the H2-receptor antagonists cimetidine and ranitidine

Aims The study was designed to investigate the effects of the H₂-receptor antagonists, cimetidine and ranitidine on the pharmacokinetics and pharmacodynamics of nebivolol in healthy volunteers. Methods Twelve healthy volunteers took part in a randomized placebo-controlled cross-over study. Each subject received on three separate occasions placebo, cimetidine (400 mg twice daily) or ranitidine (150 mg twice daily) for 24 h before and 48 h after a single oral dose of nebivolol (5 mg). Nebivolol and its individual (+) and (−) enantiomers were determined tby h.p.l.c. Results Ranitidine had no significant effect on nebivolol pharmacokinetics. Cimetidine, however, resulted in a 21–23% increase in C_max of unchanged nebivolol and of each enantiomer plus its hydroxylated metabolites. Cimetidine significantly (P<0.05) increased the AUC [mean±s.d. (95% C.I. of differences in mean)] for unchanged (±)-nebivolol [7.76±3.07 ng ml⁻¹h with placebo; 11.50±5.40 (1.75, 8.76) ng ml⁻¹h with cimetidine], (+)-nebivolol plus its hydroxylated metabolites [73.0±18.0 ng ml⁻¹h with placebo; 91.5±25.7 (1.0, 23.1) ng ml⁻¹h with cimetidine] and (−)-nebivolol plus its hydroxylated metabolites [101±32 ng ml⁻¹h with placebo; 123±38 (3.3, 27.0) ng ml⁻¹h with cimetidine]. Statistical analysis of the resting blood pressure and heart rate and exercise data did not suggest any consistent effects of ranitidine or cimetidine upon the pharmacodynamic effects of nebivolol. Conclusions There was no interaction between ranitidine and nebivolol. Although cimetidine inhibited nebivolol metabolism, it did not have a significant influence on the pharmacodynamics of the drug.     

Clinical efficacy and pharmacokinetics of artemisinin monotherapy and in combination with mefloquine in patients with falciparum malaria

1The aim of this study was to assess the pharmacokinetics, clinical efficacy and safety of artemisinin alone and in combination with mefloquine. 2Thirty-eight adults with symptomatic Plasmodium falciparum malaria were randomly assigned to receive either artemisinin (500 mg single dose followed by another 500 mg on day 1 and then 250 mg twice daily for 4 days) or artemisinin (500 mg single dose followed by 750 mg on day 1 and then 250 mg three times daily for one more day) in co-administration with mefloquine (250 mg three times daily for the first day). All drug administration was by the oral route. Patients were hospitalized at the Kibaha Designated District Hospital, Kibaha, Tanzania, for 6 days and a follow up for 3 weeks was performed. 3Treatment with the artemisinin/mefloquine combination resulted in a shorter parasite clearance time (PCT) of 24 (22, 27; 95% confidence interval) h vs 31 (27, 36) h and fever subsidence time (FST) of 14 (12, 16) h vs 20 (18, 23) h compared with artemisinin monotherapy. The 95% CI for the difference of the PCT and FST were 1.7, 12 and 3, 10, respectively. Parasites were detected in 7 out of 17 patients (41%) receiving artemisinin monotherapy at the 3rd and 4th week follow up visits. No parasites were detected after the combination therapy. 4The maximum plasma concentrations ( C_max) were similar after artemisinin monotherapy (615.4±387.0 ng ml⁻¹) and in combination with mefloquine (851.8±523.6 ng ml⁻¹). Elimination half-lives (t_1/2) were also identical at 2.2±0.6 h and 2.5±0.7 h, respectively. However, the AUC values were higher ( P<0.05) after combination therapy (3252±1873 ng  ml⁻¹ h) than after monotherapy (2234±1502 ng ml⁻¹ h). The oral clearance values were lower ( P<0.05) after combination therapy (195.4±86.9 l h⁻¹) than after monotherapy (314.3±189.4 l h⁻¹). PCT and FST normalized to initial parasitaemia correlated with AUC(0,  t) (r_s=0.56, P=0.02, r_s=0.58, P=0.01, respectively) and with C_max (r_s=0.62, P=0.01, r_s=0.68, P=0.005, respectively) in the artemisinin monotherapy only. 5One patient on the combination therapy developed a psychiatric condition and two patients on the monotherapy developed skin itch.     

Efficacy and pharmacokinetics of a new intrarectal quinine formulation in children with Plasmodium falciparum malaria

1Three groups of seven children aged 2–14 years with acute uncomplicated Plasmodium falciparum malaria received 12.8 mg kg⁻¹ quinine gluconate by the intrarectal route (new cream formulation) or 8 mg kg⁻¹ Quinimax (a Cinchona alkaloid combination) by the intramuscular or intravenous (4 h infusion) route every 8 h for 3 days. Clinical and parasitological status was similar in the three groups at enrolment. 2At 36 h, body temperature of all children of the three groups was returned to normal and remained so until day 7. 3The decrease in parasitaemia did not differ between the three groups and the time required for a 50% fall in parasitaemia relative to baseline was 12.3±5.4, 18.2±6.1 and 14.5±4.2 h in the intrarectal, intramuscular and intravenous treatment groups, respectively. Parasitaemia expressed as a percentage of initial values was not significantly different in the three groups after 48 h of treatment (7.4±16.0, 4.1±4.2 and 2.2±3.8% in the intrarectal, intramuscular and intravenous treatment groups, respectively). All the patients were aparasitaemic by day 7. 4The tolerability of the three treatments was good; in particular, no rectal irritation was reported with the cream formulation. 5The t_max occurred later after intrarectal (4.1±2.4 h) and intravenous infusion (3.8±0.5 h) than after intramuscular injection (1.6±1.3 h) (P=0.02). C_max was lower with the intrarectal (3.0±1.0 mg l⁻¹) and intramuscular routes (3.2±0.7 mg l⁻¹) than with the intravenous route (5.1±1.4 mg l⁻¹) (P=0.003). Areas under the curve (AUC(0, 8 h)) were smaller with the intrarectal (17.0±7 mg l⁻¹ h) and intramuscular routes (19.4±4.8 mg l⁻¹ h) than with the intravenous route (27.8±8.2 mg l⁻¹ h) (P=0.02). The approximate bioavailability of intrarectal quinine from 0 to 8 h was 36%vs intravenous quinine and 51%vs intramuscular quinine. 6The good tolerability and efficacy of this new intrarectal quinine formulation outweigh its low approximate bioavailability. This new approach might thus be a safe and effective alternative to intramuscular quinine injection for the treatment of children with acute uncomplicated Plasmodium falciparum malaria in the field.